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OBSTETRIC TABLES: 

COMPRISING 

GRAPHIC ILLUSTRATIONS, 

WITH 

DESCRIPTIONS AND PRACTICAL REMARKS; 
EXHIBITING ON DISSECTED PLATES 

MANY IMPORTANT SUBJECTS 



MIDWIFERY, 

BY G. SPRATT, 

mm 
SURGEON-ACCOUCHEUR. 



FIRST AMERICAN EDITION, FROM THE FOURTH AND GREATLY 
IMPROVED LONDON EDITION, 

CAREFULLY REVISED. AND WITH ADDITIONAL NOTES AND PLATES. 






- 



PHILADELPHIA: L_ 

THOMAS, COWPERTHWAIT & CO. 

No. 253 MARKET STREET. 
^ 1848. 



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Entered according to an Act of Congress, in the year 1847, by 

WAGNER & M'GUIGAN, 

in the Clerk's Office of the District Court in and for the Eastern 
District of Pennsylvania. 



STEREOTYPED BY E. 13. HEARS, 
130 RACE STREET, PHILADELPHIA. 



/ 



PREFACE TO THE FIRST AMERICAN EDITION. 



The superiority of the present work over any other series of Obstetrical illustrations, is 
universally admitted. It is a happy combination of the Picture and the Model ; combining 
the convenience of one, with the completeness of the other. To the busy practitioner, who 
wants something to refresh his memory, it obviates the necessity for continual post mortem 
examination, by supplying every point of reference he can possibly require. To the student 
it is equivalent to a whole series of practical demonstrations, with the advantage that it can be 
carried about with him and studied wherever he may desire. This is particularly the case 
with the plates explaining the use of the instruments. No single pictures could ever convey 
the same ideas, and enable the student to understand the descriptions ; but these dissected 
plates are almost equal to the Mannikin itself. The newly added representation of the Cesa- 
-rian operation, is another instance. The best views of that operation, when standing alone, 
are almost as likely to mislead as to guide correctly. This plate, however, exhibits the whole 
process in so complete and connected a manner, that nothing can be misunderstood. 

The European reputation of this work is perhaps greater than that of any other of the kind. 
Numerous copies have been imported, at different times, at a high price, and a general wish 
has been expressed for its republication here. It was, however, so novel and so difficult a 
piece of work, that no lithographers liked to undertake it ; they were afraid it would cost too 
much, and perhaps be inferior to the original. The Editor, however, having some similar 
work done by Messrs. Wagner fy McGuigan, was convinced, from what he saw of their skill, 
that it could be done by them fully equal to the original, and much cheaper. He accordingly 
proposed it to them, and undertook the necessary supervision. The result has been its issue 
to the American public, after immense labor and expense, at a much cheaper rate than it can 
be imported, and, in many respects, in a much superior style. * The additional Plates and 
Notes have been specially designed to supply all deficiencies in the original, and to bring the 
work up to the present state of Obstetrical Science. 

It is now put forward, confidently, as the best, in fact the only work of the kind in this 
country, and the attention of medical men is respectfully directed to its peculiar merits. 

AMERICAN EDITOR. 



* Th? Editor here deems it is a duty to say ; that the manner in which Messrs. Wagner & McGuigan 
have executed their part of the task, reflects upon them the highest praise. It could scarcely have been 
better performed, and proves that their establishment is eminently calculated for the proper performance 
of this kind of work. — Ed. Am. Ed. 



FRONTISPIECE. 

This plate has been carefully compiled from other works, and corrected by 
an attentive study, both of nature and the to works of art, ancient and modern. 
Every effort has been used to make it, as nearly as possible, a correct repre- 
sentation of the perfect human figure, in both sexes, so that the peculiarities of 
each may be seen, and a correct comparison made between them. 

This comparison is highly interesting in an artistic point of view, and is also, 
in many instances, of great practical value to the anatomist and physician. 



DEDICATION. 



TO 



SIR CHARLES MANSFIELD CLARKE, BART., 
physician to the queen. 

Sir, 

The high professional pre-eminence which your great talents as an Obstetrician, 

and your unwearied zeal in the alleviation of disease incidental to the female sex, have 
obtained for you, induced me to solicit the honor of placing this volume under your auspices. 
Encouraged by the flattering kindness which you have shown me, in condescending to exam- 
ine and suggest many improvements in these Tables, and honored by your permission to 
dedicate them to you, I respectfully do so, feeling assured that a work (especially intended to 
promote the relief of female suffering) could not be so well placed as under your protection. 
That you may long continue to enjoy the exalted station in your profession which you now 
hold, is the sincere wish of, 

Sir Charles, 

Your very much obliged, 

And very obedient, humble Servant, 

THE AUTHOR. 



CONTENTS. 



On the Progressive Development of the Ovum and Fcetus. 



Table I 
II 
III. Female Organs of Generation 



IV. On the Signs of Pregnancy and Development of the Uterus. 
I. B. Views of the Female Pelvis. 
II. B. Pelvis with presentations of the Fcetal Head. 

III. B. Distorted Pelvis. 

IV. B. Unimpregnated Uterus and Appendages. 

Progressive changes in the Cervix Uteri, &c. 
V. Impregnated Uteri. Extra-uterine Conception, &c. 
VI. Section of the Pelvis, exhibiting a lateral view of the Uterus in the 

progressive stages of Parturition. Examination per Vaginam, &c. 
VII. Procidentia Uteri, Enlarged Ovary, Face Presentations, &c. 
VIII. On the Application of the Forceps in the most natural position of the 
Fcetal Head. 
IX. On the Application of the Forceps in the second, third, and fourth 

POSITIONS OF THE FCETAL HEAD. 

X. Preternatural Presentations of the Fcetus. 

XI. Contents of the Gravid Uterus, Membranes, Twin Conception, &c. 

XII. Blood- Vessels of the Impregnated Uterus. 

V. B. Placenta Presentations, &c. &c. 

VI. B. On Turning. 

VII. B. On Craniotomy. 

I. C. On Hysterotomy. 
The Cephalotribe. 



TABLE OF CONTENTS. 



tt* > On the Progressive Development of the Ovum and Foetus. 

III. Female Organs of Generation. 

IV. On the Signs of Pregnancy and Development of the Uterus 
I. B. Views of the Female Pelvis. 

II. B. Pelvis with presentations of the Foetal Head. 

III. B. Distorted Pelves. 

IV. B. Unimpregnated Uterus and Appendages. 

Progressive changes in the Cervix Uteri, &c. 

V. Impregnated Uteri. Extra-Uterine conception, &c. 

VI. Section of the Pelvis, exhibiting a lateral view of the 
Uterus in the progressive states of Parturition. Exami- 
nation per Vaginam, &c. 
I. C. The Cesarean Section. 
The Cephalotribe. 



LIST OF SUBSCRIBERS. 



Adams, James, Esq. Surgeon, 39 Finsbury square. 

Aikin, C. R. Esq. Surgeon, 33 Great James 
street, Bedford Row. 

Airey, — Esq. Surgeon, Broad street, Golden 
square. 

Aldis, Dr. 13 Old Burlington street. 

Allender, G. Esq. Surgeon, High street, White- 
chapel. 

Andrews, Thomas, Esq. Surgeon, Park street. 

Appleton, James, Esq. Surgeon, 110 Holborn hill. 

Armige, T. J. Esq. Surgeon, 4 Philadelphia 
place, Hackney road, (for the Cambridge 
Heath Medical Society.) 

Ashburner, Dr. Wimpole street. 

Ashwell, Samuel, M.D. Lecturer upon Midwife- 
ry, &c. Devonshire square. 

Austin, M. Esq. Surgeon, Red Lion street. 

Badgley, Dr. 12 Lower Phillimore place, Ken- 
sington. 

Barker, — Esq. Surgeon, Edgeware road. 

Barnwell, Wm. Esq. Surgeon, 7 Queen Char- 
lotte Row, New Road. 

Bell, Sir Charles, K.G.H. 30 Brook street, 
Grosvenor square. 

Bevan, Thomas, Esq. F.L.S. Surgeon, Queen 
street, Cheapside. 

Beverley, Charles, Esq. Surgeon, Bethnal Green. 

Beetham, Arthur, Esq. Surgeon, 49 Old Broad st. 

Bird, James, Esq. M.R.C.S. Surgeon, 259 Ox- 
ford street. 

Blackett, Powell, Esq. Surgeon, Green street, 
Grosvenor square. 

Blaine, — Esq. Surgeon, Ongar, Essex. 

Blake, Dr. Kennington. 

Blandford, S. Esq. Surgeon, 20 Dover street. 



Bloxam, William, Esq. Surgeon, 4 Hanover 

street, Hanover square. 
Blundell, Dr. Great George street. 
Blundell, Thomas Leigh, M.D. Woburn place. 
Bowden, Edward, Esq. Surgeon, 135 Sloane st. 
Brian, Robert, Esq. R.N. Surgeon, 13 Spencer 

street, Northampton square. 
Bright, Dr. Richard, 11 Saville street. 
Brodie, Sir Benjamin, Bart. Saville street. 
Broster, Thomas, Esq. Surgeon, 17 Queen's 

Buildings, Brompton. 
Bryant, John, Esq. Surgeon, 50 Edgeware road. 
Bull, Thomas, Esq. Surgeon, 27 Finsbury place. 
Burrows, W. Esq. Surgeon, 1 Park st. Islington. 
Butler, James, Esq. Surgeon, 34 Seething lane. 
Butchell, S. Van, Esq. Surgeon, Percy street, 

Bedford Square. 
Byam, W. J. Esq. Surgeon, Nottingham street. 

Campbell, W. Esq. Surgeon, 23 Wilton place, 
Belgrave square. 

Camplin, John M. Esq. Surgeon, Finsbury sq. 

Carruthers, George, Esq. Surgeon, Mile-end 
road. 

Carruthers, James Mason, Esq. Surgeon, 29 
Ludgate street. 

Chinnock, H. S. Esq. Surgeon, 12 Michael's 
Place, Brompton. 

Cholmondeley, Joseph, Esq. Surgeon, 3 Not- 
tingham Place, New road. 

Clarke, Sir Charles, Bart. Physician to the 
Queen, Saville street. 

Clough, Henry Gore, Esq. Surgeon, Upper 
Southampton street. 

Clarke, Henry, Esq. Surgeon, 51 Lamb's Con- 
duit street. 



Coates, G. Esq. Surgeon, 1 Hart st. Bloorasbury. 
Conquest, Dr. Finsbury square. 
Copeland, Dr. Bulstrode street. 
Cooke, William, Esq. Surgeon, 39 Trinity square 
Cumming, R. N. Esq. Surgeon, 26 Cheyne 
walk, Chelsea. 

D'Aranda, G. Esq. Surgeon, 27 Claremont ter- 
race, Pentonville. 

Davidson, Esq. Surgeon, North street, Man- 
chester square. 

Davenport, Thomas, R. Esq. Surgeon, Harbo- 
rough, Leicestershire. 

Davies, Dr. Henry, Clifford street. 

Davis, Dr. David D. Fitzroy st. Fitzroy sq. 

Davis, James, Esq. Surgeon, 33 Red-lion sq. 

Dew, Dr. 82 Gower street, Bedford square. 

De Grave, J. F. Esq. Surgeon, 41 Friday street. 

Dendy, Walter C. Esq. Surgeon, Stamford st. 

Desomeaux, D. Esq. Surgeon, 3 Brunswick ter- 
race, Islington. 

Dover, Frederick, Esq. Surgeon, 54 Great Co- 
ram street. 

Doubleday, E. Esq. Surgeon, 170 Blackfriars 
Road. 

Drew, II. P. L. Esq. Surgeon, 79 Gower street, 
Bedford square. 

Earle, Henry, Esq. Surgeon, George street, 

Hanover square. 
Edwards, Daniel, Esq. Surgeon, Queen street, 

Cheapside. 
Elsegood, H. C. Esq. Surgeon, 14 Upper Brook 

street. 
Evans, Lewis, Esq. Surgeon, 24 Finsbury sq. 

F airhead, James, Esq. Surgeon, 51 Goswell road. 
Farquhar, Alexander, Esq. Surgeon, King's 

road, Chelsea. 
Farrar, Edward, Esq. Surgeon, 48 Guildford 

street, Russell square. 
Fernandez, Peregrine, Esq. Surgeon, 70 Lamb's 

Conduit street. 



Fincham, G. Esq. Surgeon, 5 Spring-gardens. 

Flight, W. Henry, Esq. Surgeon, St. John street 
road. 

Forbes, Dr. Argyle street. 

Freeman, Robert, Esq. Surgeon, Stony Strat- 
ford, Bucks. 

Furnival, W. H. Esq. Surgeon, Princes court. 

Gibbs, Dr. 6 Baker street. 

God rich, Francis, Esq. Surgeon, Little Chelsea. 

Gozna, Thomas, Esq. Surgeon, 29 Oxendon st. 

Granville, Dr. Grafton street. 

Graves, William Henry, Esq. Surgeon, 4 Alie 
place, Great Alie street, Whitechapel. 

Green, Joseph Henry, Esq. Surgeon, Lincoln's 
Inn Fields. 

Griffith, H. Esq. Surgeon, 39 Connaught terrace. 

Guthrie, G. J. Esq. Surgeon, 2 Berkeley street. 

Hall, Frederick, Esq. Surgeon, 14 Montague 
street, Russell square. 

Hawkins, Dr. Bisset, Golden square. 

Hall, Thomas, Esq. Surgeon, 8 Store street, 
Bedford square. 

Hallion, J. W. Esq. Surgeon, Warren street, 
Fitzroy square. 

Hardy, W. Esq. Surgeon, 79 Gower street, 
Bedford square. 

Harding, P. Esq. Surgeon, Dorset street, Port- 
man square. 

Hardey, R.Esq. Surgeon, Lower road, Islington, 

Harrison, Dr. E. Holies street, Cavendish sq. 

Harvey, William, Esq. Surgeon, 66 Great Queen 
street. 

Hellier, R. B. Esq. Surgeon, 21 Montague place, 
Russell square. 

Heygate, Thomas, Esq. Surgeon, Harborough, 
Leicestershire. 

Hensleigh, II. Esq. Surgeon, 1 Gloucester place. 

Hewson, T. A. Esq. Surgeon, King street, Co- 
vent-garden. 

Hill, J. B. Esq. Surgeon, 3 Lamb's Conduit place 

Hills, E. Esq. Surgeon, 1 Angel terrace, Isling- 
ton. 



Holmes, John Pocock, Esq. Surgeon, 21 Old 

Fish street, Doctor's Commons. 
Holt, H. F. Esq. Surgeon, Holywell street, 

Westminster. 
Hood, P. Esq. Surgeon, Norton street, Portland 

place. 
Hodgkins, Dr. New Broad street. 
Horwood, John, Esq. Surgeon, Northampton. 
Hulman, William, Esq. Surgeon, Argyle street. 
Hunter, Thomas, Esq. Surgeon, 5 Cooper's row, 

Trinity square. 
Hunter, John, Esq. Surgeon, 83 Mincing lane. 
Hunt, Henry, Esq. Surgeon, 15 Lower Brook 

street, Grosvenor square. 

Iliff, William Tiffin, Esq. Surgeon, F.L.S. New- 
ington, Surrey. 

Jenfferson, J. F. Esq. Surgeon, Barnsbury place, 

Islington. 
Johnson, James, M.D. Physician Extraordinary 

to the King, Pall Mall East. 
Jones, Henry, Esq. Surgeon, 7 Carlisle street, 

Soho square. 

Kenny, Bernard, Esq. Surgeon, Strand. 
Kerbey, W. Esq. Surgeon, Brompton row. 
King, John, Esq. Surgeon, Stepney. 
Kisch, Jos. Esq. Surgeon, 4 Broad st. Buildings. 
Kitching, G. Esq. Surgeon, Aldersgate street. 

Laisne, G. J. Esq. Surgeon, 4 Eaton square. 

Langmore, Dr. Finsbury square. 

Lavies, J. Esq. Surgeon, King st. Westminster. 

Leary, Daniel, Esq. Surgeon, 16 Parliament st. 

Lee, Dr. R. Golden square. 

Leese, Edward, Esq. Surgeon, 16 Baker street. 

Leese, Lewis, Jun. Esq. Surgeon, 11 South 

street, Finsbury square. 
Locock, Dr. Physician extraordinary to the 

Queen, 9 Hanover square. 
Loe, Charles, Esq. Surgeon, Stony Stratford 

Bucks. 



Love, J. Esq. Surgeon, Gilbert street. 

Malim, Wentworth, Esq. Lincoln's Inn Fields. 
Mart, G. R. Esq. Surgeon, 61 Frith st. Soho. 
Martin, Charles, Esq. Surgeon, 8 Connaught 

Terrace. 
M'Cann, Nicholas, Esq. Surgeon, 50 Parliament 

street. 
M'Crea, J. Esq. Surgeon, Islington. 
Merriman, Dr. Brook street, Grosvenor square. 
Menzies, R. Esq. Surgeon, 86 Upper Stamford 

street. 
Miller, Dr. S. New Basinghall street. 
Morgan, C. Esq. Surgeon, Bedford Row. 
Morrah, J. Esq. Surgeon, 62 Sloane street. 
Morgan, John, Esq. Surgeon, 22 Chapel street, 

Belgrave square. 
Morris, Dr. Princes Court. 
Morley, Henry, Esq. Surgeon, 100 Hatton 

Garden. 
Mulley, — Esq. Surgeon, 46 Hans Place, Chel- 
sea. 
Mugliston, W. S. Esq. Surgeon, Brewer street, 

Somers Town. 

Newberry, Francis, Esq. Surgeon, 28 W T ilton 

Place, Belgrave square. 
Northampton Infirmary, the Medical Library 

of the. 

Outlaw, H.M. Esq. Surgeon, Welhngbro, North- 
ampton. 
Owen, C. T. Esq. Surgeon, 146 Holburn Bars. 

Painter, R. Esq. Surgeon, Broad Way, West- 
minster. 

Pater, Richard, Esq. Surgeon, Honduras Ter- 
race, Commercial Road. 

Painter, James, Esq. Surgeon, 26 Howland 
street, Fitzroy square. 

Pardoe, Dr. 30 Great James street, Bedford Row 

Percival, William, Esq. Surgeon, Northampton. 

Perry, John, Esq. Surgeon, 59 Ebury street, 
Pimlico. 



Peregrine, Dr. 3 Half Moon street. 
Perry, John G. Esq. Surgeon, Great James st. 
Phillips, James, Esq. Surgeon, Bethnal Green. 
Ponder, William, Esq. Surgeon, 22 King street, 

Covent Garden. 
Porter, Thomas, Esq. Surgeon, 1 Euston Place, 

New Road. 
Potter, John, Esq. Surgeon, Ongar, Essex. 
Propert, John, Esq. Surgeon, New Cavendish 

street. 

Ramage, Dr. Eley Place. 

Ramsbotham, Dr. Francis H. New Broad street. 

Randall, Alfred, M. Esq. Surgeon, 50 Finsbury 

square. 
Reading, The Medical and Surgical Society. 
Reid, J. Esq. Surgeon, Charlotte st. Bloomsbury. 
Reynolds, Henry, Esq. Surgeon, 48 Prescot st. 
Riadore, Evans, Esq. F.L.S. 17 Tavistock sq. 
Rigg, Robert, Esq. Surgeon, 10 Upper George 

street, Edgeware Road. 
Ridge, John James, Esq. Surgeon, 1 Bridge 

Road, Lambeth. 
Ridge, Benjamin, Esq. Surgeon, Ditto. 
Robinson, Thomas J. Esq. Surgeon, 31 Store 

street, Bedford square. 
Robertson, Dr. Northampton. 
Rowe, Matthew, Esq. Surgeon, 24 Woburn 

Place. 
Rowe, — Esq. Surgeon, Chigwell, Essex. 
Rutherford, Samuel, Esq. Surgeon, 132 Rat- 

clifT Highway. 
Ryan, M., M.D. Lecturer on Medicine, Obste- 

tricy, &c. 4 Great Queen street, St. James's 

Park, Westminster. 

Saner, James, Esq. Surgeon, Finsbury square. 
Scard, E. Esq. Surgeon, Bernard street, Russell 

square. 
Shaw, W. Esq. Surgeon, Hampstead. 
Sharp, James, Esq. Surgeon, 19 Grosvenor 

street, West, Eaton square. 
Sigmond, Dr. 24 Dover street. 



Skegg, Robert, Esq. Surgeon, Bedford street, 

Covent Garden. 
Smith, J. S. Esq. Surgeon, 19 Trinity square. 
Smith, C. Esq. Surgeon, 10 Upper Queen's 

Buildings, Brompton. 
Smith, W. Esq. Surgeon, 79 Goswell street. 
Snitch, C. G. Esq. Surgeon, Brydges street, 

Covent Garden. 
Spencer, — Esq. Surgeon, St. John st. Road. 
Squibb, G. J. Esq. Surgeon, Orchard street, 

Portman square. 
Stevens, Frederick J. Esq. Surgeon, 190 Sloane 

street. 
Stott, Thomas P. Esq. Surgeon, 9 North Aud- 

ley street. 
Sutherland, Dr. Parliament street. 

Terry, H. Esq. Surgeon, Northampton. 

Thomson, Dr. 58 Hermitage Place. 

Thompson, Dr. Theop. 15 Keppel street, Rus- 
sell square. 

Thomas, H. Leigh, Esq. Surgeon, Leicester 
Place. 

Thomas, D. Esq. Surgeon, Upper Dorset street. 

Turner, Henry, Esq. Surgeon, 31 King street, 
Bloomsbury. 

Tuson, Edward, Esq. Surgeon, Russell Place 
Fitzroy square. 

Uwins, David, M.D. Bedford Row. 

Van Oven, Barnard, Esq. Surgeon, 25 Broad 

street Buildings. 
Vaux, C. B. Esq. Surgeon, 36 Pudding lane. 
Vickers, W. R. Esq. Surgeon, 9 Thayer street. 
Vines, Charles, Esq. Surgeon, 4 Warwick court, 

Holborn. 

Warburton, Dr. Clifford street. 

Ward, William Squire, Esq. Surgeon, Overton, 
Notts. 

Watson, Dr. Thomas, Henrietta street, Caven- 
dish square. 



Walshman, Dr. Kennington. 

Webster, George, Esq. Surgeon, 78 Connaught 

Terrace. 
White, George Francis, Esq. Surgeon, 45 

Gloucester Terrace, Commercial road. 
Whiting, Dr. Borough. 
Whitmore, Henry, Esq. Surgeon, Cold-bath 

square. 
White, Anthony, Esq. President of the College 

of Surgeons, Parliament street. 
Weatherhead, Dr. Golden square. 
Williams, J. H. B. Esq. Surgeon, Aldersgate 

street. 
Wormald, Thomas, Esq. Surgeon, 42 Bedford 

Row. 



SUBSCRIBERS IN LIVERPOOL. 

Archer, Francis, Esq. Surgeon, Renshaw street. 

Baird, Dr. Duke street. 

Bickerstaff, B. Esq. Surgeon, Rodney street. 

Banner, Maurice John, Esq. Surgeon, Rodney st. 

Bromilow, Samuel, Esq. Surgeon. 

Bryce, B., M.D. Upper Islington. 

Burrowes, John, Esq. Surgeon, Great Orford st. 

Blackburn, Thomas, Esq. Surgeon, Camden st. 

Bradley, E. Esq. Surgeon, Great Nelson street, 

North. 
Beirly, J. Esq. Surgeon. 

Chater, George, Esq. Surgeon. 

Corlet, — Esq. Surgeon, Upper Duke street. 

Callon, John, Esq. Surgeon, R.N. 

Dobbie, C. Esq. Surgeon, Brownlow Hill. 

Edwards, Dr. Bold Street. 

Eden, Thomas, Esq. Surgeon, Mount Pleasant. 

Gillon, Andrew, Esq. Surgeon, Clarence street. 

Hensman, Thomas, Esq. Surgeon, Rodney st. 
Hicks John, Esq. Surgeon, Richmond Row. 
3 



Harrison, P. Esq. Surgeon, Infirmary. 
Hayes, Thomas, Esq. 6 St. Anne street. 

Infirmary, Liverpool. 

Jeffrey, A. C. Esq. Surgeon, Great Crosshall st. 
Jones, Ellis, Esq. Surgeon, Duncan street, East. 

Lewtas, Thomas, Esq. Surgeon, Hunter street. 
Lockwood, Thomas, Esq. Surgeon, London road. 
Lane, Dr. Hunter. 

Malins, James, M.D. Lecturer on Midwifery, 

42 Bedford street. 
Martin, H. Esq. M.C.S.L. Clarence street. 
Minshull, J. L. Esq. Surgeon, Norton street. 
Marshall, James, Esq. Surgeon. 
Marshall, Buchanan, M.D. Clayton square. 
Master, — Esq. Surgeon, Old Haymarket. 
Manifold, Hugh, Esq. Surgeon, Elliot street. 
McKee, — Esq. Surgeon. 
McCulloch, — Esq. Surgeon, Duke street. 
Marshall, John, Esq. Surgeon, Duke street. 

Niell, Hugh, Esq. Surgeon, Oxford street. 
Nightingale, — Esq. Surgeon, Liverpool Fever 

Hospital. 
Nicol, John, M.D. Great George street. 

Ortt, Edmund, Esq. Surgeon, Duke street. 

Pennington, Thomas, Esq. Surgeon, London 

road. 
Park, — Esq. Surgeon, Hedge Hill. 
Parr, John, Esq. Surgeon, Camden street. 
Petrie, J. Esq. Surgeon, Parliament street. 
Pearson, David, Esq. Surgeon, Hill street. 
Powell, Edward, M.D. Islington. 
Palmer, Hall, Esq. Surgeon, Brownlow street. 
Pearson, John, Esq. Surgeon, Pembroke street. 

Rutter, Dr. St. Anne street. 

Robertson, Archdeacon, M.D. St. George street. 

Roskill, M. Esq. Surgeon, 23 Rose place. 



Shaw, John, Esq. Surgeon, Seymour street. 

Simon, T. Esq. Surgeon. 

Stubbs, Henry, Esq. Surgeon, Upper Duke st. 

Taylor, John, Esq. Surgeon, Seddon street. 
Tetlow, H. T. Esq. Surgeon, St. Anne street. 
Turner, William, Esq. 25 Rose place. 

Wainmight, H. Esq. Surgeon, Everton. 
Worthington, C. Esq. Surgeon, Rodney street. 
Whitley, Thomas, Esq. Surgeon, Islington Ter- 
race. 

CHESTER. 

Bagnall, — Esq. Surgeon. 
Griffiths, Thomas, Esq. Surgeon. 
Harrison, John, Esq. Surgeon. 
The Medical Society of Chester. 

PRESTON. 

Bradley, — Esq. Surgeon. 
Brown, R. Esq. Surgeon. 
Moore, Alfred, M.D. 
Orrell, J. Esq. Surgeon. 

WARRINGTON. 

Hall, Edward, Esq. Surgeon. 
Kendrick, James, M.D. 
Sharp, John, Esq. Surgeon. 

MANCHESTER. 

Addison, Robert, Esq. Surgeon. 

Barton, — Esq. Surgeon. 
Braid, James, Esq. Surgeon. 
Bamber, R. P. Esq. Surgeon. 
Birks, Edward B. Esq. Surgeon. 
Boyer, Robert, Esq. Surgeon. 

Carew, J. D. Esq. Surgeon. 
Cooper, W. N. S. Esq. Surgeon. 
Crowther, Robert, Esq. Surgeon. 



Dad ley, Henry, Esq. Surgeon. 
Dispensary, Library of the 

Fawdington, — Esq. Surgeon. 
Flack, J. Esq. Surgeon. 

Gardom, George, Esq. Surgeon. 
Grearis, George, Esq. Surgeon. 
Guest, W. E. Esq. Surgeon. 

Hancock, James, Esq. Surgeon. 
Harrison, John G. Esq. Surgeon. 
Hordson, Thomas, Esq. Surgeon. 
Holroyde, E. Esq. Surgeon. 

Jordan, Joseph, Esq. Surgeon. 
Johnston, Roberts, Esq. Surgeon. 
Joynson, T. N. Esq. Surgeon. 

Ker, W. Henry, Esq. Surgeon. 

Lees, Thomas, Esq. Surgeon. 
Lesse, John, Esq. Surgeon. 
Lignum, Edward, Esq. Surgeon. 
Lacy, E. Esq. Surgeon. 
Lynch, P. Jun. Esq. Surgeon. 

Macgowan, Thomas, Esq. Surgeon. 
Mann, Robert, Esq. Surgeon. 
Murray, Dr. 
Mellor, John, Esq. Surgeon. 

Noble, Daniel, Esq. Surgeon. 

Oilier, Henry, Esq. Surgeon. 
Owen, William, Esq. Surgeon. 

Partington, James Edgar, Esq. Surgeon. 

Radford, Thomas, Esq. Surgeon. 
Ransome, L. T. Esq. Surgeon. 
Roberts, Benjamin, Esq. Surgeon. 
Russell, J. Esq. Surgeon. 



Scholfiekl, R. Esq. Surgeon. 
Stephens, John, Esq. Surgeon. 

Thorp, Robert, Esq. Surgeon. 
Thompstone, S. Jun. Esq. Surgeon. 
Turner, — Esq. Surgeon. 

White, William, Esq. Surgeon. 
Whatton, W. R. Esq. Surgeon. 
W T ilson, William, Esq. Surgeon. 
Wimm, William, Esq. Surgeon. 
Windsor, John, Esq. Surgeon. 
Wood, Thomas, Esq. Surgeon. 

DUBLIN. 

Armstrong, L. Esq. Surgeon, French street. 

Beatty, J. E., M.D. York street. 

Campbell, H. W., M.D. Lying-in Hospital. 
Clarke, Patrick Dillen, M.D. South Anne street. 

Darley, Henry, M.D. Kildare street. 
Doyle, Thomas, M.D. Talbot street. 
Fleming, — Esq. Surgeon, Talbot street. 
Flood, Valentine, M.D. 19 Blessington. 

Gawley, E. Esq. Surgeon, Swinford, County 
Mayo. 

Hansard, James J. Esq. Surgeon. 

Hara, C. W. Esq. Surgeon, Coombe Lying-in 

Hospital. 
Hayden, G. J. Esq. Surgeon, Harcourt street. 
Hughes, Charles, Esq. Surgeon, Rutland square. 
Ieland, R. S. Esq. Surgeon. 
Kennedy, E., M.D. Lying-in Hospital. 
Lebatt, M.D. Merrion Row. 
Mannsell, Henry, M.D. York street. 
McKeever, Thomas, M.D. Marlborough street. 
Montgomery, W. F. M.D. Molesworth street. 
Peebles, John, M.D. Dorset street. 

Shanahan, Bryan Richard, M.D. Lying-in Hos- 
pital, Townsend street. 

Young, A. K. Esq. Surgeon, 50 Abbey street. 
Young, E. Esq. Surgeon, Upper Ormond Quay. 



BOLTON. 

Binden, — Esq. Surgeon. 
Denham, Joseph, Esq. Surgeon. 
Haworth, Thomas, Esq. Surgeon. 
Knott, Edwin, Esq. Surgeon. 
Pendlebury, James, Esq. Surgeon. 
Robinson, J. M. Esq. Surgeon. 

WIGAN. 

Daglish, — Esq. Surgeon. 
Hanott, W. Esq. Surgeon. 
Shaw, — Esq. Surgeon. 

BIRMINGHAM. 

Aaron, Isaac, Esq. Surgeon. 

Baynham, J. M. Esq. Surgeon. 

Cox, Edward T. Esq. Surgeon. 

Chavasse, P. H. Esq. Surgeon. 

Hall, G. Esq. Surgeon. 

Hobson, Benjamin, Esq. Surgeon, 142 Snow Hill. 

Ingleby, John, Esq. Surgeon. 

Jukes, Alfred, Esq. Surgeon. 

Ledsam, J. J. Esq. Surgeon. 

Palmer, F. S. Esq. Surgeon, 16 Colmore Row. 

Porter, J. W. Esq. Surgeon. 

Swinson, E. S. Esq. Surgeon, Cannon Hill. 

Taylor, Thomas, Esq. Surgeon. 

Vaughton, Thomas, Esq. Surgeon. 

Watts, J. W. Esq. Surgeon. 

Wright, John, Esq. Surgeon. 

Wilcox, — Esq. Surgeon. 

WOLVERHAMPTON. 
Coleman, Edward H. Esq. Surgeon. 
Gatis, James, Esq. Surgeon. 
Bodger, W. J. Esq. Surgeon. 

BILSTON. 

Best, N orris, Esq. Surgeon. 
Cooper, R. S. Esq. Surgeon. 
Dickenson, F. W. Esq. Surgeon. 



COVENTRY. 

Bicknell, Edward, Esq. Surgeon. 
Barton, W. Ashton, Esq. Surgeon. 
Smith, John, Esq. Surgeon. 

DERBY. 

Borough, Charles, Esq. Surgeon. 

Wright, John, Esq. Surgeon to the Derbyshire 

General Infirmary. 
Webster, John, Esq. Surgeon. 

SHEFFIELD. 

Boultbree, Henry, Esq. F.L.S. 

Clark, G. W. Esq. Surgeon. 

Ernest, Robert, M.D. Sheffield General In- 
firmary. 

Favell, W. Esq. Surgeon. 

Gillott, Edward, Esq. Surgeon. 

Hall, John, Esq. Surgeon. 

Jackson, William, Esq. Surgeon. 

Jackson, Henry, Esq. Surgeon. 

Martin, Edward, Esq. Surgeon. 

Overend, Wilson, Esq. Surgeon to the Sheffield 
General Infirmary. 

Ray, James, Esq. Surgeon. 

Turten, George, Esq. Surgeon. 

Taylor, R. S. Esq. Surgeon. 

Thomson, Gorden, M.D. 

Wild, James, Esq. Surgeon. 

Wood, H. Esq. Surgeon. 

WAKEFIELD. 

Bennett, John, Esq. Surgeon. 
Dawson, William, Esq. Surgeon. 
Statter, S. Esq. Surgeon. 



HUDDERSFIELD. 

Bradshaw, J. Taylor, Esq. Surgeon, New st. 
Tatham, Thomas Robert, Esq. Surgeon. 
Huddersfield, the Medical Library of 

LEEDS. 

Bulmer, George, Esq. Surgeon, Assembly 

Court. 
Cass, W. R. Esq. Surgeon, 11 Albion street. 
Garlick, John, Esq. Surgeon, 21 Park Row. 
Hare, S. Esq. Surgeon, 26 East Parade. 
Hey and Son, Messrs., Surgeons, Albion 

Place. 
Hay, William, Esq. Surgeon, 23 Park square. 
Horton, R. H. Esq. Surgeon, Hoi beck. 
Nunnerly, — Esq. Surgeon, Wellington street. 
Price, W. Esq. Surgeon, Park Row. 
Pullan, Richard, Esq. Surgeon, Hunslet. 
Smith, Samuel, Esq. Surgeon, Park Row. 
Teale, Thomas Ridge, Esq. Surgeon, 22 Albion 

street. 
Taylor, J. Mackenzie, Esq. Surgeon. 
Ward, — Esq. Surgeon, 41 Kirkgate. 

STOCKPORT. 

Brooke, John, Esq. Surgeon. 

Cheetham, Thomas, Esq. Surgeon, Hill Gate. 

Cheetham, S. H. Esq. Surgeon. 

Douns, George, Esq. Surgeon. 

Flint, Richard, Esq. Surgeon. 

Medd, John, Esq. Surgeon. 

Norris, H. Esq. Surgeon. 

Rayner, J. W. Esq. Surgeon. 

Taylor, J. Esq. Surgeon. 

Welhamtour, Jun. Esq. Surgeon. 



ADDITIONAL SUBSCRIBERS. 



BATH. 

Barnard, J. F. Esq. Surgeon. 
Barter, Thomas, Esq. Surgeon. 
Browne, E. Esq. Surgeon. 
Bush, George F. Esq. Surgeon. 
Chilton, Joseph, Esq. Surgeon. 
Church, W. Esq. Surgeon. 
Field, Frederick, Esq. Surgeon. 
Fryer, W. H. Esq. Surgeon. 
George, R. F. Esq. Surgeon. 
Greville, Dr. 
Goldstone, Robert, Esq. 
Hicks, Charles, Esq. Surgeon. 
Hill, Edward, Esq. Surgeon. 
Howell, John W. Esq. Surgeon. 
Hunt, E. Esq. Surgeon. 
King, George, Esq. Surgeon. 
Kilvert, John, Esq. Surgeon. 
Massy, Hugh, Esq. Surgeon. 
Norman, George, Esq. Surgeon. 
Skeate, E. Esq. Surgeon. 
Soden, J. S. Esq. Surgeon. 
Spender, J. C. Esq. Surgeon. 
Slater, Charles Phillot, Esq. Surgeon. 
Spry, George, Esq. Surgeon. 
Wright, Edward, Esq. Surgeon. 
White, John, Esq. Surgeon. 

BRISTOL. 

Bell, John, Esq. Surgeon. 

Blake, John, Esq. Surgeon. 

Brady, — Esq. Surgeon. 

Bryant, Samuel, Esq. Surgeon. 

Burroughs, S. B. Esq. Surgeon, Mall, Clifton. 

Chandler, John Moss, Esq. Surgeon. 

Frankis, B. F. Esq. Surgeon, 72 Stokes Croft. 

Fryer, Thomas, Esq. Surgeon, 52 RadclhTHill. 

Goldney, S. Esq. Surgeon, Clifton Dispensary. 

Humpage, E. Esq. Surgeon, 12 King Square. 

James, H. G. Esq. Surgeon. 

Kelson, Joseph James, Esq. R.C.S. Surgeon. 



Leonard, Isaac, Esq. Surgeon. 

Lansdown, J. G. Esq. Surgeon, St. James Barton 

Maurice, W. Esq. Surgeon. 

Olliver, A. Esq. Surgeon. 

Rogers, George, Esq. Surgeon. 

Sweeyne, H. Esq. Surgeon. 

Searle, J. Clarke, Esq. Surgeon, 14 College st. 

Stanton, J. Esq. Surgeon, Dowry sq. Clifton. 

Wilson, John Grant, Esq. Surgeon, 17 Bridge st. 

GLOUCESTER. 

Bedwell, J. R. Esq. Surgeon, Barton street. 

Carden, H. D. Esq. Surgeon. 

Clutterbuck, Charles, Esq. Surgeon, Eastgate 

street. 
Hicks, T. Esq. Surgeon, College Green. 
Parsons, George, Esq. Surgeon, College Green. 
Playne, George, Esq. Surgeon. 
Spencer, J. H. F., M.D. Albion House. 
Wilton, John W. Esq. Surgeon. 

CHELTENHAM. 

Agg, Thomas, Esq. Surgeon, Portland street. 

Cooke, C. J. Esq. Surgeon. 

Eves, Augustus, Esq. Surgeon to the Casualty 

Hospital. 
Fortnom, James, Esq. Surgeon. 
Murly, S. H. Esq. Surgeon. 
Newman, R. Esq. Surgeon. 
Whitmore, W. Esq. Surgeon, 49 St. George's 

place. 



Hammond, T. M. Esq. Surgeon, Brixton, Surrey 

Denbigh, W. Esq. B. M., Newington. 

Bowen, B. Esq. Surgeon, Harrow. 

Hewlett, Thomas, Esq. Surgeon, Harrow. 

Hickman, Charles, Esq. Surgeon, Kentish Town 

Blackstone, Joseph, Esq. Surgeon, High street, 
Camden Town. 

Bland, Cornelius, Esq. Surgeon, 5 Arbour Ter- 
race, Commercial Road. 



Baines, J. Esq. Surgeon, Bradford. 
Adye, M. Esq. Surgeon, Ditto. 
Plimmer, George, Esq. Surgeon, Melksham. 
King, J. R. Esq. Surgeon, Ditto. 

Barker, W. D. Esq. Surgeon, Devizes. 
Clark, William, Esq. Surgeon, Ditto. 
Trinder, Charles, Esq. Surgeon, Ditto. 
Ogilvie, George J. Esq. Surgeon, Calne. 
Page, George, Esq. Surgeon, Calne. 
Spencer, H. Esq. Surgeon, Chippingham. 
Jeston, Alfred, Esq. Surgeon, Malmsbury. 

SOMERSET. 
Tomkins, W. Esq. Surgeon, Yeovil. 
Moore, John, Esq. Surgeon, Ditto. 
Webb, J. Esq. Surgeon, Ditto. 

Spicer, N. W. Esq. Surgeon, Chard. 
Burt, G. R. Esq. Surgeon, llminster. 
Wing, John, M.D. Taunton. 

Higgins, Charles Hayes, Esq. Surgeon, Ditto. 
Alford, Henry, Esq. Surgeon, Ditto. 

Pyne, W. C. Esq. Surgeon, Wellington. 
Ludball, John Gore, Esq. Surgeon, Wivelis- 

combe. 
Edwards, A. F. Esq. Senior Surgeon to the 

Wiveliscombe Infirmary. 
Haviland, James, Esq, Surgeon, Bridgewater. 
Hudson, Thomas, Esq. Surgeon, Wells. 
Davies, Frederick, Esq. Surgeon, Wells. 
Gale, F. Esq. Surgeon, Glastonbury. 

James, W. T. Esq. Surgeon, Ditto. 
Newman, George, Esq. Surgeon, Ditto. 
Gale, Alfred, Esq. Surgeon, Shipton Mallet. 
Gane, J. M. Esq. Surgeon, Frome. 
Payne, Thomas Henry, Esq. Surgeon, Frome. 
Yeatman, J. C. Esq. Surgeon, Frome. 
Bush, E. Esq. Surgeon, Bruton. 
Taylor, James, Esq. Surgeon, Castle Cary. 

WORCESTERSHIRE. 

Morris, Edward, Esq. Surgeon, Worcester. 
Meears, J. Esq. Surgeon, Ditto. 

Sheppard, J. P. Esq. Surgeon, Ditto. 

Hill, R. Esq. Surgeon, Ditto. 

1 Iurley, E. Esq. Surgeon, Ivy House, Ditto. 
Budd, H. W. Esq. Surgeon, Ditto. 

Owen, James, Esq. Surgeon, Ditto. 



Appleton, J. G. Esq. Surgeon, Evesham. 
Rickitts, M. Esq. Surgeon, Droitwich. 
Thursfield, Thomas, Esq. Surgeon, Kidder- 
minster. 
Jotham, G. W. Esq. Surgeon, Kidderminster. 
Cole, J. Esq. Surgeon, Bewdley. 
Cooper, Thomas, Esq. Surgeon, Stourbridge. 
Cartwright, — Esq. Surgeon, Dudley. 
Hall, J. P. Esq. Surgeon, Ditto". 

Fereday, Samuel W. Esq. Surgeon, Dudley. 

STAFFORDSHIRE. 
Spilsbury, E. A. Esq. Surgeon, Walsal. 
Edwards, F. A. Esq. Surgeon, Ditto. 
Day, J. Esq. Surgeon, Ditto. 

Hamblin, Henry, Esq. Surgeon, Ditto. 
Fletcher, A. A. Esq. Surgeon, Ditto. 

GLOUCESTERSHIRE. 

Tate, George, Esq. Surgeon, Tukesbury. 

Gardner, W. Esq. Surgeon, Painswick. 

Gyde, A. Esq. Surgeon, Ditto. 

Bedwell, J. Adolphus, Esq. Surgeon, Ciren- 
cester. 

Warner, Thomas, Esq. Surgeon, Cirencester. 

Ireland, — Esq. Surgeon, Ditto. 

Mantell, George, Esq. Surgeon, Farringdon, 
Berks. 

CHESHIRE. 
Nightingale, J. Esq. Surgeon, Window. 
Baird, J. W., M.D. Knutsford. 

Hewitt, J. H. Esq. Surgeon, Ditto. 

Wagstafle, H. Esq. Surgeon, Ditto. 

Dean, R. Esq. Surgeon, Ditto. 

Vaudrey, Thomas, Esq. Surgeon, Cheadle. 

Lupton, B. Esq. Surgeon, Ditto. 

Ockleston, Robert, Esq. Surgeon, Ditto. 

Bullock, J. Esq. Surgeon, Congleton. 

Jackson, J. R. Esq. Surgeon, Ditto. 

Bland, J. Esq. Surgeon, Park Green, Maccles- 
field. 

Furth, J. Esq. Surgeon, Ditto, Ditto. 

Buckenall, Esq. Surgeon, Park st. Ditto. 

Lellemand, J. T. Esq. Surgeon, Park Green, 
Macclesfield. 

Gossling, G. J. Esq. Surgeon, Fordergate, Mac- 
clesfield. 



Goodwin, Robert D. Jun. Esq. Surgeon, Ash- 
bourne. 
Shorland, W. Esq. Surgeon, Ilchester. 
Collyns, C. Esq. Surgeon, Dulverton. 
Flexman, W. Esq. Surgeon, South Molton. 
Robert Shute, Esq. Surgeon, Morpeth. 
Edward Storer, Esq. 
Robert Hawdon, Esq. 
Henry Hunt, Esq. Surgeon, Bedford. 

EDINBURGH. 
Dr. J. Mars. 
Dr. J. H. Davidson. 
Dr. Abercrombie. 
Dr. Simpson. 
Dr. Malcolm, F.R.C.P.E. 
Charles, Sidey, Esq. Surgeon. 
John Macwhorter, M.D. 
Thomas Pagan, M.D. 

J. S. Alexander, Esq. Surgeon, 31 Alva street. 
James Murray, Esq. F.R.C.S.L. 
James Crighton, Esq. Surgeon. 
P. Mitchelhill, Esq. Surgeon, 1 Downie Place. 

GLASGOW. 
James Brown, M.D. Abercromby Place. 
John Macfarlane, M.D. 14 St. Vincent street. 
Thomas Watson, Esq. Surgeon, West Nile st. 
James Paterson, M.D. Great Hamilton street. 
James Jeffray, M.D. Professor. 
Andrew Mackie, M.D. Portland street. 
Alexander Forbes, M.D. 8 Portland street. 
William Strang, Esq. Surgeon, Nicholson st. 
J. Agnew, Esq. Surgeon, 1 King street, Trades- 
town. 
J. Black, Esq. Surgeon, Charlotte street. 
Thomas Gray, Esq. Surgeon, Gallowgate. 
Alexander Adams, M.D. Garnet Hill. 



Robert Garroway, Esq. Surgeon, Bridgeton. 

Robert Adam, Esq. Surgeon, Calton. 

John Dick, Esq. Surgeon, 2 London street. 

Thomas Cunningham, Esq. Surgeon, 1 Norfolk 
street. 

James Cassels, Esq. Surgeon, 24 Sanchiehall 
street. 

Thomas Marshall, M.D. Demonstrator. 

Alexander Morton, Esq. Surgeon, 37 Crown 
street. 

Robert Hay, Esq. Surgeon, Great Clyde street. 

William Cullen, Esq. Surgeon, 287 Gallow- 
gate. 

J. Mactear, M.D. 12 George street. 

A. Craig, Esq. Surgeon, 288 High street. 

James Paterson, M.D. 1 Washington street. 

C. Douglas, Esq. Surgeon, King street. 

Alexander Stewart, Esq. Surgeon, 111 C, Rigg 
street. 

John Harvey, M.D. 43 Cadogan street. 

E. J. McDonnell, M.D. 114 Saltmarket street. 

John Macewan, M.D. 12 Pitt street. 

William Thomas Squier, M.D. Calton. 

J. Robertson, Esq. Surgeon, Broomiclaw. 

James Wilson, M.D 

GREENOCK. 

Robert Walker, M.D. 

John Speirs, M.D. 

J. R. Speirs, M.D. 

William Turner, Esq. Surgeon, R.N. 

H. W. Buchanan, M.D. 

R. Bruce, Esq. Surgeon. 

John Smith, Esq. Surgeon. 

Thomas Hugh Donnelly, M.D. 

Charles Auld, M.D. 

John Fox, M.D. M.R.C.S.L. 

A. D. Stewart, Esq. Surgeon. 



Loney, William, Esq. Surgeon, Roe street, 
Macclesfield. 

Sainter, J. D. Esq. Surgeon, Chestergate, Mac- 
clesfield. 

GLOUCESTERSHIRE. 
Williams, J. B. Esq. Surgeon, Tetbury. 
White, Frederick B. Esq. Surgeon, Ditto. 
Gardener, E. B. Esq. Surgeon, Stroud. 

LANCASHIRE. 

Broadbent, R. Esq. Surgeon, Altringham. 
Blease, Thomas, Esq. Surgeon, Ditto. 
Wilson, Thomas, Esq. Surgeon, Ditto. 
Wood, Esq. Surgeon, Rochdale. 

Wardleworth, H. Esq. Surgeon, Ditto. 
Lumb, W. Birgley, Esq. Surgeon, Ditto. 
Coventry, Alex. Esq. Surgeon, Ditto. 
Coates, John, Esq. Surgeon, Ditto. 

Taylor, E. Esq. Surgeon, Middleton. 
Scholfield, Jas. Esq. Surgeon, Ditto. 
Sorby, Wm. Esq. Surgeon, Eccles. 
Mercer, Thomas, Esq. Surgeon, St. Helens. 
Garton, William, Esq. Surgeon, Ditto. 
Gaskell, J. Esq. Surgeon, Ditto. 

Blundell, J. Esq. Surgeon, Ditto. 

Garton, John, Esq. Surgeon, Prescot. 
Garthside, J. H. Esq. Surgeon, Chorley. 
Pollard, J. Esq. Surgeon, Ditto. 

Skaife, John, Esq. Surgeon, Blackbourn. 
Barlow, R. B. Esq. Surgeon, Ditto. 
Cochrance, Esq. Surgeon, Great Bridgewater 

street, Manchester. 
Cookson, George, Esq. Surgeon, Manchester. 
Pickop, Eli, Esq. Surgeon, Blackburn. 
Barlow, R. B. Esq. Surgeon, Ditto. 
Grime, John, Esq. Surgeon, Ditto. 
Dean, Robert, Esq. Surgeon, Clitheroe. 
Arkwright, John, Esq. Surgeon, Ditto. 
Garstang, J. Esq. Surgeon, Ditto. 

Pinder, W. Esq. Surgeon, Colne. 
Cockcroft, Thomas, Esq. Surgeon, Colne. 
Hargraves, Henry, Esq. Surgeon, Burnley. 
White, Stephen, Esq. Surgeon, Ditto. 
Coultate, Esq. Surgeon, Ditto. 



STAFFORDSHIRE. 
Rooker, A. Esq. Surgeon, Darlaston. 

Rooker, James Yates, Esq. Surgeon, Ditto. 
Jackson, William, Jun. Esq. Surgeon, West 

Bromwich. 
Savage, J. Esq. Surgeon, West Bromwich. 
Lees, F. Esq. Surgeon, Wednesbury. 
Lishman, R. William, Esq. Litchfield. 
Chavasse, C. A. Esq. Surgeon, Ditto. 
Salt, Thomas, Esq. Surgeon, Rugeley. 
Field, William, Esq. Surgeon, Ditto. 
Bradbury, G. G. Esq. Surgeon, Stafford. 
Perrin, W. J. Esq. Surgeon, Ditto. 
Masfen, John, Esq. Surgeon, Ditto. 
Wogan, W. Esq. Surgeon, Ditto. 

Fowke, H. Esq. Surgeon, Ditto. 

Hubert, W. A. Esq. Surgeon, Penkridge. 
Lindop, W. Esq. Surgeon, Newport. 
Higgins, R. G. Esq. Surgeon, Ditto. 
Greatrex, C. G. Esq. Surgeon, Eccleshall. 
Swift, G. Esq. Surgeon, Ditto. 

Fallows, J. E. Esq. Surgeon, Stone. 
Masefield, William, Esq. Surgeon, Stone. 
Hecley, J. Esq. Surgeon, Stone. 
Berrow, Wm. Esq. Surgeon, Burton-upon- 

Trent. 
Allen, S. Sept. Esq. Surgeon, Ditto. 

Langley, B. Esq. Surgeon, Tutbury. 
Lassetter, R. Esq. Surgeon. Uttoxeter. 

Hewgill, Arthur, M.D. Ditto. 

Chapman, James, Esq. Ditto. 

Woolrich, Thomas, Esq. Surgeon, Ditto. 
Hawthorn, H. Esq. Surgeon, Ditto. 

Hawthorn, Frederick, Esq. Surgeon, Ditto. 
Walker, J. Esq. Surgeon, Burslem. 
Hayes, R. Esq. Surgeon, Longton. 
Eardly, B. Esq. Surgeon, Hanly. 
Head, Thomas, Esq. Surgeon, Hanly. 
Astle, Aneb. Esq. Surgeon, Newcastle. 
Bourne, Esq. Surgeon, Cheade. 
Sutton, Esq. Surgeon, Ditto. 
Tomkinson, R. Esq. Surgeon, Cheade. 
Staffordshire Infirmary. 

Kirkland and Dalby, Messrs., Surgeons, Ashby. 
Ingle, W. N. Esq. Surgeon, Ashby. 
Skevington, J. Esq. Surgeon, Ashbourne. 



Besley, W. H. Esq. Surgeon, 40 Southernhay, 
Exeter. 

Harris, John, Esq. Surgeon to the Devon and 
Exeter Hospitals. Exeter. 

Couper, Thomas, Esq. Surgeon, 9 Northernhay, 
Exeter. 

Parker, J. W. Esq. Surgeon, The Close, Exeter. 

Luscombe, S. Esq. Surgeon to the Exeter Hos- 
pital. 

Edye, John, Esq. Surgeon, Exeter. 

Webb, Charles H. Esq. Surgeon, Ditto. 

Bennett, James, Esq. Surgeon, Bartholomew 
Yard, Exeter. 

Warren, W. B. Esq. Surgeon, Exeter. 

Waters, A. Esq. Surgeon, Exmouth. 

Kane, William, Esq. Surgeon, Exmouth. 

Black, Glass, Esq. Surgeon, Ditto. 

Gervis, George, Esq. Surgeon, Teignmouth. 

Cartwright, William, Esq. Surgeon, Ditto. 

Harvey, J. B. Esq. Surgeon, Ditto. 

Holman, W. B. Esq. Surgeon, Crediton. 

Hugo, Thomas, Esq. Surgeon, Ditto. 

Hainworth, Charles, Esq. Surgeon, Ditto. 

Gabriel, William, Esq. Surgeon, Cullompton. 

Maunder, Haine W. Esq. Surgeon, Ditto. 

Reed, W. H. Esq. Surgeon, Tiverton. 

The Medical Book Club, Ditto. 

Davy, Thomas, Esq. Surgeon, Ottery, St. Mary. 

Wreford, Samuel, Esq. Surgeon, Ditto. 

Tinney, W. S. Esq. Surgeon, Ditto. 

Goss, James, Esq. Surgeon, Dawlish. 

Bowden, R. B. Esq. Surgeon, Ditto. 

Scarbrough, John L. Esq. Surgeon, Shaldon. 

Jolly, Rowe William, Esq. Surgeon, Torquay. 

Cartwright, Henry, M.R.C.S. Ditto. 

Blackaller, Bartlett J. M.R.C.S. Ditto. 

Tanner, M. C, M.R.C.S. Ditto. 

Bailey, W. L. Esq. Surgeon, Teignmouth. 

Hunter, Thos. Esq. Surgeon, Budleigh Salterton. 

Vowell, M. Esq. Surgeon, Ditto. 

Goomidge, J. J. Esq. Surgeon, Paington. 

PLYMOUTH, DEVONPORT, &c 

Fortescue, Herbert, Esq. Surgeon, 32 George 

street, Plymouth. 
Andrews, John Henry, Esq. Surgeon, Plymouth. 
4 



Fuge, William, Esq. Surgeon, George Terrace, 
Plymouth. 

Denton, — Esq. Surgeon, Plymouth. 

Rattenbury, William, Esq. Surgeon, 10 George 
place, Plymouth. 

Stewart, T. H. Esq. Surgeon, Princess square, 
Plymouth. 

Taylor, Charles, Esq. Surgeon, Sussex place, 
Plymouth. 

Welch, M. Esq. Surgeon, St. Aubyn street, 
Devonport. 

Tripe, Cornelius, Esq. Surgeon, Ker st. Devon- 
port. 

Watson, R. Esq. Surgeon, St. Aubyn street, 
Devonport. 

Robertson, — Esq. Surgeon, Union street, 
Stonehouse. 

Row, Dr. Ker street, Devonport. 

Rolston, G. Esq. Surgeon, St. Aubyn street, 
Devonport. 

Buxton, J. C. Esq. Surgeon, 32 Union street, 
Stonehouse. 

Isbell, John, M.D. F.L.S. Stonehouse. 

Dansey, George, Esq. Surgeon, Trafalgar place, 
Stoke. 

Lower, — Esq. Surgeon, Clowance street, De- 
vonport. 

Bates, — Esq. Surgeon, Torpoint, Cornwall. 

Littleton, Nicholas, Esq. Surgeon, Saltash, Ditto 

Risk, J. Erskine, M.D. Ditto. 

Pode, M. J. Esq. Surgeon, Plympton. 

DORSET. 
Simmonds, M. Esq. Surgeon, Sherborne. 
Fussell, Ernest, Esq. Surgeon, Ditto. 
Highmore, M. Esq. Surgeon, Ditto. 

WILTS. 

Coates, Henry, Esq. Surgeon, Salisbury. 
Hurd, Charles, Esq. Surgeon, Ditto. 
Andrews, William, Esq. Surgeon, Ditto. 
Winzar, John, Esq. Surgeon. Ditto. 

Welch, E. A. R. Esq. Surgeon, Downton. 
LangstafT, George, Esq. Surgeon, Wilton. 
Pyle, Charles, Esq. Surgeon, Amesbury. 
Seagram, W. Lye, Esq. Surgeon, Warminster. 



Turner, William, Esq. Surgeon, Newcastle. 
Bell, David, M.D. Carlisle. 
Oliver, Richard, Esq. Surgeon, Carlisle. 
Meddle, Thomas, Esq. Surgeon, Dalston, near 

Carlisle. 
James, Richard, M.D. Carlisle. 
Longmire, William, Esq. Surgeon, Kendal. 
Havens, Robert, Esq. Surgeon and Apothecary, 

Kendal. 
Gough, Thomas, Esq. Surgeon, &c. Kendal. 
Allen, Thomas, Esq. Surgeon, Nottingham. 
Davidson, Robert, Esq. Surgeon, Ditto. 
Chicken, Thomas, Esq. Surgeon, Ditto. 
Holstenholme, James, Esq. Surgeon, Ditto. 
Sanders, Edward, Esq. Surgeon, Maidstone. 
French, Edward, Esq. Surgeon, Ditto. 

TUNBRIDGE WELLS, &c. 

Hargraves, I. Esq. Surgeon, Tunbridge W T ells. 

Trustram, Charles, Esq. Surgeon, Ditto. 

Cornwall, James, Esq. Surgeon, Ditto. 

Sopwith, H. Lindsell, Esq. Surgeon, Ditto. 

Wisden, William, Esq. Surgeon, Ditto. 

Clouter, — Esq. Surgeon, Calverly place, Tun- 
bridge Wells. 

West, W. J. Esq. Surgeon, Tunbridge. 

Savery, John, Esq. Surgeon, Hastings. 

Duke, Walter, Esq. Surgeon, Ditto. 

Ranking, Robert, Esq. Surgeon, Ditto. 

Jones, George, Esq. Surgeon, St. Leonard's, 
Hastings. 

BRIGHTON, LEWES, &c. 

Green, — Esq. Surgeon. 

Winter, J. B. Esq. Surgeon, 24 Cannon place, 
Brighton. 

Dix, Edward, Esq. Surgeon, 7 Old Steine, 
Brighton. 

Blaker, Henry, Esq. Surgeon, Brighton. 

Rugg, Richard, Esq. Surgeon, Ditto. 

Paine, J. Esq. Surgeon, Grand Junction Pa- 
rade, Brighton. 

Scruse, George, Esq. Surgeon, Lewes. 

Chatfield, John S. Esq. Surgeon, Ditto. 

Moon, Henry, Esq. Surgeon, Ditto. 

Harris, William, Esq. Surgeon, Worthing. 

Marter, E. William, Esq. Surgeon, Ditto. 



Fletcher and Wardropers, Messrs., Surgeons, 

Arundel. 
Hills, George, Esq. Surgeon, Arundel. 
Byass, Richard, Esq. Surgeon, Ditto. 
Caffin, William, Esq. Surgeon, Chichester. 
Knott, John, Esq. Surgeon, Ditto. 

Gruggen, Messrs., Surgeons, Ditto. 

HANTS. 

White, Richard, Esq. Surgeon, Portsmouth. 
Hellard, George B. Esq. Surgeon, Ditto. 
Scottj E. J., M.D. Portsea. 
Tate, John J. M.D. Ditto. 
Batchelor, Richard, Esq. Surgeon, Southsea. 
Cooper, Thomas, Esq. Surgeon, Portsea. 
Garington, — Esq. Surgeon, Ditto. 
Engledue, M. C, M.D. Southsea. 
Rundle, W. S. Esq. Surgeon, Gosport. 
Williams, — Esq. Surgeon, Ditto. 
Jenkins, John, Esq. Surgeon, Ditto. 
Stamland, James, Esq. Surgeon, Fareham. 
Andrews, Edward, Esq. Surgeon, Titchfield. 
Banks, W. H. Esq. Surgeon, Ryde, Isle of Wight 
Pedder, George, Esq. Surgeon, Ditto. 
Daverds, J. Cowes, Isle of Wight. 
Corfe, George B. Esq. Surgeon, Southampton. 
Caldwell, Edward, Esq. Surgeon, Mellbrook, 

Southampton. 
Lyford, Henry G. Winchester. 
Marter, — Esq. Surgeon, Poole. 
West, John, Esq. Surgeon, Poole. 
Rowe, John Reynolds, Esq. Surgeon, Wim- 

bome, Dorset. 
Hawes, Robert, Esq. Surgeon, Ditto. 

Place, G. A. Esq. Surgeon, Ditto. 

Knott, William, Ditto. 

Welch, James II. Esq. Surgeon, Christ church, 

Hants. 
Scriven, — Esq. Surgeon, Weymouth, Dorset. 
Tucker, W. Esq. Surgeon, Bridport, Ditto. 
Workman, Thomas, Esq. Surgeon, Basingstoke. 
Woodward, Thomas C. Esq. Surgeon, Andover. 
Smith, John, Esq. Surgeon, Weyhill. 

EXETER, &c. 
Ottley, Drewry, Esq. Surgeon, 3 Southernhay, 

Exeter. 



West, Charles Turner, Esq. Surgeon. 
Brereton, Charles, Esq. Surgeon, Beverly. 

HALIFAX. 

Holroyd, James, Esq. Surgeon. 
Hodgson, John, Esq. Surgeon. 
Smith, Solomon, Esq. Surgeon. 
Suttliffe, Joshua, Esq. F.L.S. Surgeon. 

BRADFORD. 
IHingworth, J. A. Esq. Surgeon. 
Kirby, Robert, Esq. Surgeon. 
Ramsbothom, John H. Esq. Surgeon. 
Brook, Lionel John, Esq. Surgeon, Pontefraet. 

YORK. 

Allen, James, Esq. Surgeon. 

Allen, E. Thomas, Esq. Surgeon, 4 Spence Gate. 

Binns, Abraham, Esq. Surgeon. 

Coates, Amos, Esq. Surgeon. 

Champney, George, Esq. Surgeon. 

Dodsworth, Benjamin, Esq. Surgeon. 

Hey, Richard, Esq. Surgeon. 

Hopps, John, Esq. Surgeon. 

Hopps, George, Esq. Surgeon, Red House. 

Hope, Frederick, Esq. Surgeon. 

Husband, W., M.D. 

Marshall, William, Esq. Surgeon. 

Simpson, Dr. 

Walker, Thomas K. L. Esq. Surgeon. 

Wisker, Thomas R. Esq. Surgeon. 

THIRSK. 

Lambert, William, Esq. Surgeon. 
Wilson, E. C. Esq. Surgeon. 

DURHAM. 

Balfour, William, Esq. Surgeon. 
Green, William, Esq. Surgeon. 
Hepple, William, Esq. Surgeon. 

SUNDERLAND. 
Embleton, C. C. Esq. Surgeon, 10 Church st. 
Gregory, R. Esq. Surgeon. 
Mordey, W. Esq. Surgeon. 
Oliver, William, Esq. Surgeon. 
Torbock, Thomas Reddish, Esq. Surgeon. 
Thompson, H. Esq. Surgeon. 



Cook, John, Esq. Surgeon, Church street. 

Harrison, J. G. Esq. Surgeon, Villiers street, 
Bishop Wearmouth. 

Happer, Thomas, M.D. Monkwearmouth Shore 

White, Thomas, Esq. Surgeon, Ditto. 

Ward, John, Esq. Surgeon, 5 Church street. 

Swan, G. Esq. Surgeon, Church street, Monk- 
wearmouth. 

NEWCASTLE. 

Alexander, J. S., M.D. 

Brady, Henry, Esq. Surgeon, High street, Gates- 
head. 

Bennett, Francis, Esq. Surgeon, Gateshead. 

Carter, Charles T. Esq. Surgeon. 

Downie, George, Esq. Surgeon, Bigg Market. 

Edgcome, James, Esq. Surgeon. 

Hardcastle, William, Esq. Surgeon, Westgate st. 

Henzel, C. R. Esq. Surgeon, 81 Percy street. 

Liddell, John, Esq. Surgeon. 

Morrison, William, Esq. Surgeon. 

Marshall, John, Esq. Surgeon, Northumberland 
street. 

Preston, William C. Esq. Surgeon. 

Tulloch, Benjamin, Esq. Surgeon, New Bridge 
street. 

NORTH SHIELDS. 

Bramwell, W. Esq. Surgeon. 

Stephens, T. Esq. Surgeon, Saville street. 

Lietch, D. R., M.D. Tynemouth. 

Bowlby, H. Esq. Surgeon, South Shields. 

Coward, William, Esq. Surgeon, Ditto. 

Emery, J. Esq. Surgeon, Ditto. 

Lawrence, Samuel, Esq. Surgeon, Ditto. 

Ridley, R. B. Esq. Surgeon, Ditto 

Trotter, Charles, Esq. Surgeon, Stockton.- 

Ripley, John, Esq. Surgeon, Whitby. 

Taylorson, John, Esq. Surgeon, Whitby. 



Cole, William, Esq. Surgeon, Pickering. 
Birdsill, — Esq. Surgeon, Ditto. 

Dightin, Messrs. W. B. and C. Surgeons, 

Northallerton. 
Harper, A. E., M.D. Darlington. 

Macfarlan, Donald, M.D. Ditto. 

Jackson, Thomas Hayes, M.D. Ditto. 
Haslewood, W., M.D. Ditto. 



Pratt, John, Esq. Surgeon, 48 Upper Baker 

street, Regent's Park. 
Price, Allen Foord, Esq. Surgeon, Prospect 

place, Deptford. 
Mark, James, Esq. Chemist, &c. Broadway, 

Deptford. 
Coale, John, Esq. Surgeon, St. Albans. 
Rayner, W. Esq. Surgeon, Uxbridge. 
Johnson, Robert, Esq. Surgeon, Bromley, Mddx. 
Wallace, John Andrew, Esq. Surgeon, Bow 

road, Middlesex. 
Bottomley, George, Esq. Surgeon, Croydon. 
Lashmar, Charles, Esq. Surgeon, Croydon. 
Messeena, J. N. Esq. Surgeon, 73 Poplar. 
Bain, William P., M.D. Blackwall. 
Jago, F. R. Esq. Surgeon, Hammersmith. 
Simoens, J. Esq. Surgeon, Twickenham. 
Paul, Dr. Rickmansworth. 
Crowdy, C. W. Esq. Surgeon, Brixton Hill. 
Ward, F. Esq. Surgeon, Balham Hill, Surrey. 
Bainbridge, W. Esq. Surgeon, Upper Tooting. 
Drummond, George, Esq. Surgeon, Croydon. 
Coates, H. Esq. Surgeon, Elizabeth Terrace, 

New Cross. 
Sankey, Edward, Esq. Surgeon, 5 Thurow 

place, Hackney Road. 
Evans, T. J. Esq. Surgeon, 5 James's place, 

Hackney Road. 
Ryan, John, Esq. Surgeon, 3 High street, 

Shoreditch. 
West, George, Esq. Surgeon, 9 High street, 

Shoreditch. 
Vandenburgh, A. S. Esq. Surgeon, Bethnal 

Green Road. 
Moore, Edward, Esq. Surgeon, 49 Bethnal 

Green Road. 
Pearce, Samuel, Esq. Surgeon, Bethnal Green 

Road. 
Franks, G. Esq. Surgeon, 90 Blackfriars road. 
Ward, John Rodney, Esq. B.M. Leyden, Old 

Kent Road. 
Richardson, William, Esq. Surgeon, Bayswater. 
Owen, Jeremiah, Esq. Surgeon, Stockwell com. 
Smith, Jos. Esq. Surgeon, Clapham Road place. 
Bellamy, G. L. Esq. Surgeon, 386 Oxford st. 
Smith, W. Esq. Surgeon, 21 Dorset street, 

Portman square. 



Green, H. Esq. Surgeon, 3 Tavistock square. 
Morries, J. D., M.D. F.R.S.E. Sackville street. 
Warren, H. Esq. Surgeon, Gravesend. 
Richards, G. B. Surgeon, Gravesend. 
Knight, W. B. Esq. Surgeon, Folkstone. 
Major, James, Esq. Surgeon, Folkstone. 
Bell, W. Esq. Surgeon, Rochester. 
Ponder, W. Esq. Surgeon, Chatham. 
Edge, P. Hulme, Surgeon, Manchester. 
Cheetham, H. Esq. Surgeon, Ashton. 
Oldham, Robert, Esq. Surgeon, Ashton. 
Kay, Samuel, Esq. Surgeon, Ashton. 
Rawntree, J. Esq. Surgeon, Oldham. 
Morley, James, Esq. Surgeon, Oldham. 
Morley, George, Esq. Surgeon, Leeds. 
Longden, Fred. Esq. Surgeon, Sheffield. 
Shearman, E. James, Esq. Surgeon, Rotherham. 
Wilkinson, Henry, Esq. Surgeon, Rotherham. 
Robinson, J. Esq. Surgeon, Rotherham. 
Morey, J. E. Esq. Surgeon, Doncaster. 
Storrs, Robert, Esq. Surgeon, Doncaster. 
Rickard, J. Esq. Surgeon, Doncaster. 
Hall, G. Esq. Surgeon, Birmingham. 
Snowden, G. S. Esq. Surgeon, Ramsgate. 
Snowden, H. 0. Esq. Surgeon, Ramsgate. 
Rutley, G. E. Esq. Surgeon, Dover. 
Sibbit, E. Esq. Surgeon, Dover. 
Coleman, T. Esq. Surgeon, Dover. 
Waddington, J. Esq. Surgeon, Margate. 
Neame, J. Esq. Surgeon, Margate. 
Hoffman and Son, Messrs., Surgeons, Margate. 
Hunter, George Yeates, Esq. Surgeon, Margate. 
Price, — Esq. Surgeon, Margate. 
Havell, C. Esq. Surgeon, Canterbury. 
Major, D. B. Surgeon, Canterbury. 
Bray, F. R. Esq. Surgeon, 89 Mary street, 
Hampstead Road. 

HULL. 

Casson, Richard, Esq. Surgeon. 
Craven, Robert, Esq. Surgeon. 
Fielding, G. H. Esq. Surgeon. 
Fowler, N. Esq. Surgeon. 
Hardey, Robert, Esq. Surgeon. 
Lowther, G. W. Esq. Surgeon. 
Sleight, Robert, Esq. Surgeon. 
Sharpe, Richard, Esq. Surgeon. 



TABLES I. AND II. 

ILLUSTRATING THE DEVELOPMENT OF THE OVUM AND FCETUS. 

PRELIMINARY OBSERVATIONS AND REMARKS. 

To investigate the subject of conception would be foreign to a purely practical work on 
obstetrics ; but the subject of reproduction of the human species is so deeply interesting, that 
we think a brief outline of the modern physiological theory of impregnation, and the progressive 
growth of the foetus to maturity, will not be misplaced, nor prove uninteresting to many of 
our readers. The works of Blumenbach, Ryan, Velpeau, Spallanzani, and many others, may 
be consulted by those who wish to investigate minutely this interesting subject. That 
conception should follow sexual congress, it appears essential on the part of the female that 
the ovaria contain some of their vesicles in a healthy condition ; on the part of the male, that 
the testes be in a healthy state. The male semen being transmitted through the uterus, and 
by the tuboe Fallopianse to the ovaries, stimulates one of the vesiculse Graafianse which contains 
the ovum or germ.* 

When fecundation takes place, the fimbriated extremity of one of the tubes expands and 
embraces the ovary, the impregnated ovulum bursts and escapes, with its external envelope, 
together with a small portion of the liquid peculiar to the Graafian vesicle, and thus it passes 
into the Fallopian tube, along which it is conveyed into the uterus. The precise time at which 
the ovulum enters the womb after fecundation is not known. Although it is generally supposed 
to be about a week or two in its journey from the ovaria to the cavity of the uterus, it appears 
probable that the time may be much shorter. It is said to have been detected in the uterus 
so early as the eighth day, by Home, Walker, and others. Dr. Granville states that he saw a 
perfect ovulum ejected from the womb fourteen days after a single sexual congress, which had 
taken place the day after the cessation of the menses. f 

The ovulum contains the primordial parts of the foetus, though on its first entrance into the 
uterus they can scarcely be detected, on account of their minuteness and transparency. It 
has two membranous coverings, having a gelatinous substance interposed between them, the 
chorion and amnion^, the former being the outer, the latter the inner covering : these, with a 
fluid (liquor amnii) secreted by the amnion, constitute the ovum. 



* An ovulum exists in each of the vesicles of Graaf, which the ovarium contains in women who have 
reached maturity. 

t Granville's Graphic Illustrations of Abortions, &c. 

t Velpeau says this membrane does not exist before the twelfth day. 
4 



From the moment of conception, the internal surface of the uterus acquires an increased 
action, and secretes a delicate, lacerable, and cribri-form membrane (decidua) which may be 
divided into two laminae, the one in contact with the uterus, the other with the ovum. 

According to Prevost, Baer, and Dumas, the blood is formed independently of the heart. 
The arteries, veins, and heart, are formed successively. The development of the nervous 
system commences from the circumference of the embryo, proceeding towards the centre ; 
hence the lateral nerves of the head, trunk, and pelvis, are developed, whilst the cerebro-spinal 
system is yet in a liquid state. 

Of the digestive organs the intestinal canal is the first to appear : it consists, during the first 
days of its formation, of a curved open tube, extending the whole length of the embryo, placed 
before the vertebral column. It communicates with the vesicula umbilicalis.* It extends and 
expands, and its superior extremity, the mouth, opens about the fourth or fifth week ; the 
inferior extremity, the anus, opens about the seventh ; the outlines of the stomach are visible 
about the ninth week.f Before the seventh day we cannot perceive any thing in the uterus 
which indicates the presence of a new being. On the tenth day a semi-transparent, greyish 
flake may be perceived, of an indeterminate form.:]: From the twelfth to the thirteenth day, 
the presence of a vesicle, the size of a pea, containing a thick fluid, in the middle of which 
swims an opaque spot, presents the first lineaments of the new being that bears the name of 
embryo : it is enveloped by the membranes chorion and amnion ; the weight is equal to one 
grain. 

The embryo may be perceived with the naked eye at the fourteenth day after conception 
(vide fig. 1, 2, and 3, Table 1). On the twenty-first day, it resembles, in form, a large ant 
or lettuce seed (Burton), its length is from 4 to 5 lines, and weight from three to four grains : 
at this period the different parts of the foetus present a little more consistence, and those which 
are to form bones pass into a cartilaginous state (vide fig. 4 and 5). On the thirtieth day it 
is about the size of a horse fly, and resembles a worm bent together ; at this period we may 
perceive, although faintly, some traits of the principal organs; the head appears as large as 
the rest of the body; there is also, in the former, black dots marking the spots for the eyes ; 
its weight is from nine to ten grains, and its length from ten to twelve lines (vide fig. 6 and 7). 
At the period of forty-five days, the development of the foetus in various parts becomes well 
determined, the superior and inferior extremities appear under the form of globular tubercles, 
the former preceding the latter by a short period of time ; the body lengthens, but keeps the 
ovoid figure; blackish spots indicate the presence of the eyes, the mouth, and the nose; 
weight one drachm, length one inch.§ At from sixty to seventy days, the various parts of the 
fcetus become progressively developed, the black spots which represent tire eyes enlarge, the 
eylids are visible, the nose becomes a little prominent, the mouth enlarges, the external concha 
of the ear becomes distinctly delineated, the brain is soft and pulpy, the neck is defined, and 
the heart is fully developed. At ninety days, three months, the development of all the essential 
parts of the fcetus becomes perfectly defined; the eyelids are distinctly delineated, but closely 
shut: the lips are very distinct and drawn together, the organs of generation are exceedingly 
prominent in the male as well as in the female, the penis in the former and the clitoris in the 



* Meckel, Wolf, Ok en. 1 Velpeau. 

t The precise time at which the ovulum enters the womb is not exactly known. 

§ The measure and weight vary more or less during every period of pregnancy. 



latter are remarkably elongated.* The heart beats with force, and the larger vessels carry 
red blood ; the fingers and toes are defined, the muscular system begins to characterise itself; 
weight, about two ounces and a half; length, from four to five inches. 

At one hundred and twenty days, or four months, the development of the foetus in all its 
parts is remarkably increased, the brain and spinal marrow acquire more consistence, the 
muscular system is distinct, and here and there we meet with some cellular tissue. The 
abdomen is fully covered in, and the intestines are no longer visible ; in the latter, a little 
meconium collects ; weight, seven to eight ounces. 

At one hundred and fifty days, or five months, the development of every part of the foetus 
is very considerably increased; the lungs enlarge, and are susceptible of experiencing a 
certain dilatation. The cutaneous envelope acquires at this period much consistence, the 
epidermis is stronger and thicker, the situation of the nails is determined, and the meconium 
is more abundant and lower in the intestines ; length, eight or ten inches ; weight, fourteen 
or sixteen ounces ; intellectual faculties void. 

At one hundred and eighty days, six months, the foetus is increased in its shape and 
formation, the nails are marked, a little down appears on the head, the first indication of 
hair ; the cellular tissue is abundant, and a little adipose substance is deposited in its cells : 
length, from nine to ten or twelve inches; weight, from one and a half to two pounds; 
intellectual functions void. 

At two hundred and ten days, seven months, every part of the foetus has progressively 
increased in volume, size, and weight; the nails are formed, the hair appears, the testicles 
descend, the meconium increases in the large intestines, and the bony system is nearly 
complete: length, from twelve to fourteen inches; weight, two and a half to three 
pounds ; intellectual functions void. 

From the seventh to the ninth month, the successive development of the foetus is limited 
to mere weight and size.f At the period of nine months, the cutaneous, arterial, and 
capillary 'systems become very active, the skin appears colored, and the perspiration 
is established. The intellectual functions void ; but the animal functions are well developed, 
especially that of taste ; the child is sensible of pain, of hunger, and of heat and cold : weight, 
from five to eight pounds ; length, from eighteen to twenty-two inches. 



* The difference of sexes may be known from other circumstances besides the sexual organs, such as 
the particular formation of the head, extremities, thorax, abdomen, and dorsal spine. 

t Although the growth of the various parts of the fcetus bears a proportion to the general development 
of its body, that part of the body which is below the navel measures in length less than the part above 
it, until the full period of gestation, when the navel marks the precise centre of the foetus. This circum- 
stance will assist us in forming an opinion respecting the age of any foetus. (Fodere, Chaussier.) 



DESCRIPTION OF TABLES I. AND II. 

Fig. 1. — An ovum from eight to twelve days, of the natural size. The floc- 
culent surface of the chorion is readily distinguished, and occupies the whole of 
the circumference. 

Fig. 2. — An ovum of about twelve days, laid open. 

Fig. 3. — A magnified view of the same ovum. 

a.a.a. — The villous surface of the chorion. 

b.b. — Reticulated magma or the allantois,* placed between the chorion, c.c.c. 
and the amnion g. 

d. The embryo, e. The umbilical or intestinal vesicle.t 
f. The umbilical cord.J 

Fig. 4. — An ovum of about twenty-one days, laid open. 

a.a.a. The chorion spread open and retained by the pins. 

b. The amnion open, leaving the embryo to be seen completely bare. 

Fig. 5. — The same ovum (fig. 4) magnified. 

a. The head of the embryo. B. The eyes. c. The mouth. 



* The allantois is a vessel or sac which projects from the lower end of the anal intestines ; it appears 
about the fourth week, and by the sixth it has nearly disappeared ; it communicates with the bladder by 
the urachus, (a canal,) which is found impervious after the first three or four months of gestation. 
(Meckel, Dutrochet, Baer, and others.) 

t The umbilical vesicle measures about half an inch in length ; it is situated immediately against the 
anterior surface of the embryo, but gets further from it at the end of the first month, when it is found on 
the outside of the sheath of the cord. It is composed of a granular membrane ; it contains a whitish 
liquid, which gradually becomes thicker, and ultimately hardened. The vesicle withers and becomes 
opaque ; it receives the omphalo-mesenteric vessels. It disappears about the third month. 

t The umbilical cord appears about the end of the third week, and then consists of a vein and two 
arteries, the urachus, a species of gelatine of a ropy nature, a portion of the intestinal canal, (larger in 
proportion as the embryo is younger,) the vesicula umbilicalis in part, and the omphalo-mesenteric vessels. 
The three last disappear after the third or fourth month of gestation. 



TABLE I 




HI 















G. Spratt del 



Verier fit W Guitar, hth 



LABU If. 








^Pmfm**--*. 



G Spraft del 



Wafoer S: M c Guig'an lith 



d. The neck. e. The superior or thoracic extremities. 

f. The abdominal, or inferior extremities. 

g. The extremity of the coccyx, h.h. The arch of the spine. 
i. The region of the liver. 

k. The pedicle of the umbilical vesicle. /. The vesicle. 

Fig. 6. An ovum of the natural size, laid open, about twenty days old. 
Fig. 7. A magnified view of fig. 6, a.a.a. The circumference of the chorion, 
with a portion of its flocculent surface, to be seen on one side. 

b. The head of the embryo greatly bent forward. 

c. The mouth already very visible. 

d. The thoracic tubercles, or rudiments of the superior extremities. 

e. The abdominal tubercles, or rudiments of the inferior extremities. 

f. The point of the coccyx. 

g. The remains of the vitelline liquor, contained in the umbilical vesicle, hard- 
ened and forming a tumor. 

h. Remains of another small vesicle which was formed near the ring of the 
umbilicus. 

ii. Umbilical vein. e.e. Umbilical arteries. 
m.m. Omphalo-mesenteric vessels.* 

Fig. 8. An ovum, of from five to six weeks, laid open. 
a.a.a. The circumference of the chorion, b.b. Villosities of the placenta. 
c.c.c. The amnion, d. Head of the embryo, e.e. The temples. 
f. Root of the nose, or interval between the eyes. g. The right ear. 
h. The superior extremities, j. The inferior or pelvic extremities. 
i. The abdomen, k. Sexual organs. 
b.b. The umbilical cord, already turned spiral. 
m. The swelling containing the intestinal portion. 

Fig. 9. A foetus of the age of forty-five days. 



* These vessels consist of an artery and vein, they accompany the cord as far as the navel, through 
which they pass into the abdomen. These vessels disappear as the vesicula umbilicalis becomes 
obliterated. 
5 



Fig. 10. A foetus of the age of two months or sixty days. 

Fig. 11. A foetus of the age of three months, enclosed in the amnion. 

Fig. 1. (Table II.) A foetus of the age of four months. 

Fig. 2. (Table II.) A foetus of the age of five months, with the placenta 
and membranes. The chorion is laid open to exhibit the foetus enveloped in 
the amnion. The amnion is seen attached to the centre of the internal surface 
of the placenta, through which the navel chord passes. The external surface of 
the placenta is seen covered by the chorion and decidua. 




X 



v 












TABLE III. 

ILLUSTRATING THE FEMALE ORGANS OF GENERATION. 

A. The Mons Veneris. 

B.B. The Labia externa, majora, vel pudendi. 

C. The Perineum anticus. 

The Mons Veneris is a prominence situated on the Symphysis Pubis, arising 
from each side of the groin, composed of common integuments, fat, fibrous and 
cellular substance, and numerous sebaceous follicles. Its breadth is about two 
inches, and covered with hair after puberty. The inferior part bifurcates to 
form the Labia externa. 

The Labia externa take their rise from the termination of the mons veneris, 
and descend to the perineum anticus, where they unite and form the fourchette 
or frsenum (marked D in the drawing). The points at which the Labia unite 
above and below are called superior and inferior commissures, and the fissure 
formed by the Labia is called the genital fissure, or sinus pudoris, vulva or 
pudendum. The Labia are composed of common integuments, cellular sub- 
stance and fat, and are covered with hair after puberty. Their internal 
surfaces are smooth, of a pink color, and supplied with numerous sebaceous 
and mucous follicles.* 

The Labia are dense and in opposition before puberty ; but become elongated, less dense, 
and bluish, after marriage. 

The Labia are sometimes found united at birth. The surfaces of the Labia very frequently 
cohere, so as to close up the genital fissure, leaving only a small opening for the passage of 
the urine. This cohesion is not unfrequently caused by uncleanliness in those who are 
attacked with excoriation or ulceration. 

On separating the Labia externa, the Clitoris, §c., are brought into view. 

A. The Clitoris. B.B. The Nymphce, or Labia minora. C. The Hymen. 
D. Meatus urinarius. E. The orifice of the Vagina. 

The Clitoris is an elongated substance, about two inches in length, formed 
of two cavernous, spongy, vascular bodies. It has a round, free extremity, 

* These follicles sometimes give rise to an acrid discharge, not unfrequently mistaken for gonorrhcea. 



called its glans, which is enveloped by skin or prepuce, which terminates in the 
Labia minora. It resembles the male penis ; it becomes erect during coition, 
and is the principal seat of voluptuousness. The Clitoris arises from the ischia- 
pubic branches, and is attached to the pubis by a suspensory ligament. 

The Clitoris sometimes increases to the length of four or five inches. The Clitoris is 
sometimes the seat of cancer and cauliflower excrescence. 

The Nymphoz, or labia minora, are two continuations from the prepuce of 
the clitoris and labia externa; they diverge and descend on either side to 
about the middle of the labia externa, where they terminate insensibly on 
the internal surface. They are formed of fine thin vascular and spongy tissue, 
and consist internally of adipose and cellular tissue ; they are firm, and of a 
reddish color. 

The nymphoe in some persons are naturally elongated, and in some countries, as Hin- 
dostan, Persia, and Turkey, they produce so much inconvenience as to require extirpation. 
In the foetus, and at birth, the nymphce pass the external labia; in virgins, they are hidden 
within the vulva; but in women who have had children they become elongated, less firm, and 
lose their rosaceous color. 

Meatus urinarius, or orifice of the urethra, is a small round aperture 

situated about an inch below the clitoris, and about one-third of an inch 

above the entrance into the vagina ; it is surrounded by small depressions, 
called lacunae. 

The situation of the orifice of the urethra demands particular attention, on account of the 
introduction of the catheter. The best position for introducing the catheter, is for the patient 
to lie on her back with her knees separated and elevated. The operation will be best per- 
formed by the operator standing on the patient's right side, with the catheter, previously 
oiled, in his right hand, then to carry his left hand over the right thigh of the patient, and 
with the index finger to separate the labia and nymphae, the finger must then be passed 
downward about an inch below the clitoris, till it arrives at the orifice of the urethra. The 
right hand, with the catheter, is to be carried under the patient's thigh, and the point of the 
instrument directed to the extremity of the index finger, when, with a little dexterity, it 
readily slips into the urethra. The relative positions of the parts are so much altered in cases 
of procidentia and inversio uteri, " that, although the catheter must be introduced and carried 
forwards to the pubes, with the point directed in the usual course, yet, when it has reached 
the symphysis, its handle must be so elevated towards the abdomen that the extremity of the 
instrument should be directed towards the knees. Under other circumstances, such as the bladder 
being over the pubes, when the abdomen is pendulous, the handle must be as much depressed, 



immediately after the point has cleared the symphysis pubis."* Previous to introducing the 
catheter, the stilette should be withdrawn, and a moistened bladder tied on the extremity of 
its handle, into which the urine may flow. This plan prevents the bed being wetted, which 
is an almost unavoidable circumstance, as the operation is commonly performed. 

The vagina is the canal which extends from the genital fissure to the 
uterus, passing between the bladder and rectum. In the virgin state, it is about 
one inch in diameter, but much more capacious in married women, and those 
who have had children : it is capable of great contraction and dilatation. 
It is from three to five inches in length ; the superior or upper part encircles 
the cervix uteri. 



The vagina is lined by a mucous membrane, which affords a secretion which prevents 
adhesion of its surfaces. This secretion is increased in leucorrhcea. 



Fig. 2. — On folding down the part marked D, the uterus, &c. are brought 
into view. 

A. The fundus of the uterus. B.B. The round ligament, the left of 
which is seen passing through the ring of the external oblique muscle C, and 
terminating on the mons veneris. E. A portion of the small intestines. 
C. A portion of the external oblique muscle turned aside, to shew the uterus in 
its situation. 

D.D. The iliac arteries, veins, and nerves. 

The uterus.^ This organ is situated between the bladder and rectum, it is 
destined for the reception of the foetus. The form of the unimpregnated uterus 
is somewhat pyreform ; when impregnated, its shape is oval. The uterus is di- 
vided into fundus, corpus, and cervix ; the fundus is that portion which is above 
the insertion of the fallopian tubes ; the corpus is the portion between the fund- 
us and cervix, and the latter is the narrow portion below the corpus or body. 
The unimpregnated uterusj is about three inches in length, two inches in 
breadth at the fundus, and one inch at the cervix. The cavity of the uterus is 
somewhat triangular, and is lined by a continuation of the villous covering of 
the vagina. The substance of the uterus is composed of muscular fibres, nerves, 
arteries, veins, and absorbents, connected by dense cellular structure. Its nerves 

* Conquest's Outlines. 

t Fig. 1. Table IV, in the Obstetric Tables, represents the unimpregnated uterus and its appendages. 

1 See fig. 1. Table IV, Obstetric Tables. 



are supplied from the meso-colic plexus, the sacral and great sciatic. Its arteries 
are four, two spermatic and two hypogastric : these vessels freely anastomose. 

The ovaries or seminal glands of the woman, the secreting organs of the germ, 
are situated near the sides of the uterus, enclosed in the posterior fold of the 
broad ligament, are oblong, oval, about the size of a bean or almond, and of a 
yellow grey color, and contain the ova, in number from eight to twenty. At 
puberty, the ovaries become developed and active, and, by sympathy, produce a 
series of changes in the uterus, mammae, larynx, &c. 

The uterine tubes, (Tubas Fallopianae), are two small canals, arising from the 
lateral angles of the fundus of the uterus, four or five inches long, and about the 
size of a goose-quill ; they pass through the middle fold of the broad ligament. 

Fig. 3. — On turning down fig. 2, the uterus is represented in situ. A. The 
uterus, b.b. The fallopian tubes, fimbriae, and ovaries. C. The bladder, d. 
The rectum passing down behind the uterus, e.e. The round ligaments, f.f. 
The broad ligaments. 

We must observe, that, to have this and the former view of the contents of 
the pelvis, (fig. 2), it is necessary that the pelvis be placed horizontally ; other- 
wise, the uterus, &c, would appear to be placed somewhat too high. 



TABLE IV. 

ILLUSTRATING THE SIGNS OF THE DIFFERENT EPOCHS OF PREGNANCY. 

Signs. — Pregnancy may be distinguished by presumptive or rational signs, and positive 
or sensible signs. The signs presumptive or rational, are those which cause a belief or sup- 
position that pregnancy exists. Although numerous, these signs are very uncertain, and we 
can only form conjectures by their presence. Among these signs, are those which affect the 
entire economy : these are the general presumptive signs. There are others which manifest 
their presence on a point far removed from the economy : these are the particular or local 
signs. The first are drawn from all the changes that a woman experiences in the regular and 
natural functions, in her habits, her longings, and her particular fancies, the effects of which 
are marked by the paleness of the face and a certain alteration in the features which belongs 
alone to pregnant women, but which the most, experienced eye cannot always recognise. 

The particular or local signs are of a more positive nature : alone, they do not indicate 
to a certainty the reality of pregnancy ; but they deserve all the attention of the 
practitioner. These signs are, first, the suppression of the menses ; 2d, the enlargement 
and expanding of the abdomen ; 3d, the discoloration and brownish appearance of the 
areola, the swelling of the breasts, and the moisture from the nipple. 

There are two remarkable circumstances in the life of women, during the time the 
monthly courses are suppressed without the health being sensibly affected : these two circum- 
stances are pregnancy and suckling ; but far from the suppression of the menses being a 
positive sign of pregnancy, it is not always even a rational sign — nothing being so variable or 
so subject to derangement as this evacuation ; any more than its constant and regular 
appearance is a formal proof that the woman is not pregnant, since there are numerous 
examples which demonstrate that, although pregnant, some women have not ceased to men- 
struate, at least during the first months of gestation. 

So soon as a woman perceives that her abdomen enlarges and expands, she thinks herself 
pregnant ; above all, if these signs are accompanied by the suppression of the menses. 

It is true that pregnancy causes the enlargement and expanding of the abdomen ; but 
causes foreign to pregnancy, which may produce this appearance, are too numerous to allow 
us to accord to this sign all the value which it merits in the case of a true pregnancy. 

Besides, the abdomen does not visibly enlarge until after the third month ; and as the 
feeling at this short period of pregnancy can only furnish vague data, we must only pro- 
nounce with much reserve upon the enlargement of the abdomen, even as a rational sign of 
pregnancy. 



Later, and when pregnancy is far advanced, the size of the abdomen adds little to its 
certainty ; other signs, more positive, leave no doubt about its presence. 

The sympathy which exists between the uterus and the breasts explains sufficiently the 
influence that pregnancy exercises upon the latter. In general, this influence is not felt till 
towards the fourth month, nor is it discontinued until the accouchement, a period when the 
functions are established in these organs. However, it is not uncommon to see the breasts 
swell from the beginning of pregnancy, and even furnish by the nipple a secretion sufficiently 
distinguished. It is these anomalies which throw such uncertainty upon the swelling of the 
breasts as presumptive signs of pregnancy ; although it is certain that it is one of the least 
equivocal, because it is uncommon, in false pregnancy, that the causes which occasion them 
produce upon the breast the same effects as true pregnancy. Alone, however, the swelling 
of the breasts and the secretion from the nipple would be far from being sufficient motives for 
believing in the presence of pregnancy ; since we have examples in women who were really 
not pregnant, and with very young girls, where these phenomena were present. 

4th. The dark brownish color which encircles the areola and the nipple is generally enough 
looked upon as a sign of pregnancy ; because it is demonstrated that the dropsy, and all 
other circumstances which may produce the enlargement of the abdomen, have no action 
upon the breasts, and do not give place to any change of form or color in these organs. 
However, this sign will not always suffice to ensure the presence of pregnancy. 

There are some women having the areola dark, and others who, even having had several 
children, have not experienced any change in this part, it always having remained of a pale 
pink color, even after many pregnancies. 

The sensible signs, positive or demonstrative, of pregnancy, are of two species. The 
former, which are draw T n from the sight and feeling, form its experimental or practical history. 
They make known the changes that the womb experiences, during pregnancy, in its form, its 
figure, and its situation : this is what may be called the physical phenomena of pregnancy. 

The second are not accessible to our senses ; they result from the changes that the womb 
undergoes in its organization during the course of pregnancy, changes which operate in virtue 
of common functions of which it is already possessed, and which form the physiological phe- 
nomena of pregnancy ; these are its true rational signs. 

Experimental detail of pregnancy. — At the end of the first month, nothing indicates to the 
accoucheur, at least in a perceptible manner, not even that pregnancy exists, nor even that 
the womb may be in a state of plenitude or action : any, that is to say rational, signs, not being 
yet manifest ; and the general accounts given by some authors are too vague to allow us to 
place much faith in them. 

It is not the same at the end of the second month (60 days accomplished). The practice 
of feeling may, by attention, enable us to distinguish the state of the fulness of the womb, as 
well as that the slight change made in its form and size make us presume on the existence of 
pregnancy. 

During the whole course of the first month, the womb does not appear to experience any 
sensible change in its form or size ; it is even probable that, far from acquiring any increase, 
it, on the contrary, contracts, as if it would embrace more closely the new production 
enclosed in its bosom. 

At the end of the second month, its size is sensibly increased, its form is become 
rounded, it fills up the greater part of the pelvis; but the abdomen, far from enlarging, 
becomes more contracted, more tender, and sometimes a little painful. 






After the third month, its size increases, as also its length, the fundus rises to the height 
of the region of the pubis and superior aperture or brim of the pelvis.* 

The finger, introduced into the interior of the vagina, will perceive its form rounded, 
globular, and equal ; it can be raised without making the woman feel any perceptible pain ; 
the abdomen is slightly tumefied by the rising of the intestines, (see fig. 2.) ; but the neck of 
the uterus has not experienced any change, and consequently cannot furnish any perceptible 
sign of pregnancy. 

The use of the stethescope, if it were possible to apply it in the interior of the vagina, 
could furnish, at this period, valuable results to confirm the existence of an organised body in 
the uterus. 

At the end of the fourth month, the uterus emerges from out of the pelvis ; its fundus rises 
to two or three fingers' breadth above the region of the pubis. The abdomen is sensibly 
enlarged ; but it is at the side of the vagina, by the touch, that we can perceive with certainty 
the presence of pregnancy. It is not impossible to derive certain information by the ballotte- 
ment ;f the head of the foetus having acquired at this period sufficient size and weight to obey, 
in a perceptible manner, the motion impressed upon it. It is not even uncommon that, at the 
same period, the woman should feel the first motion of her child. 

At the end of the fifth month, there no longer remains any doubt as to the presence of 
pregnancy ; all the signs, be they sensible or be they rational, unite in crowds to confirm it. 
We find the fundus of the uterus on a level with the umbilicus. 

Feeling makes manifest the presence of the child, and the touch, executed by a careful 
and experienced hand, shews it with the greatest facility. 

At the end of the sixth month, the rapidity with which the expanding of the uterus operates 
is such, that the extremity of the organ is raised two fingers' breadth above the umbilicus ; its 
usual form is that of an ellipsis, greatly lengthened from fundus to cervix. We can easily 
perceive, by feeling, the head of the child through its distended coats. One particularity 
characterises the end of the sixth month : the neck, which up to this period had not taken 
any part in the development of the body and of the fundus of the uterus, begins to experience 
a little enlargement towards its base, its inferior orifice begins slightly to open, the neck 
itself, a little tumefied, becomes softer, and every thing announces that it is at length disposed 
to participate in the general dilatation of the womb. 

In the course of the seventh month, the fundus of the womb, which still rises a little, 
begins to enter into the epigastric region ; but its elevation no longer presents the same 
activity : on the contrary, it keeps decreasing, and from the elliptical, the womb tends more 
and more to take a spherical form, which contributes to the widening of the cervix uteri. 

The cervix, in fact, loses more and more of its hardness, \ its inferior orifice widens in a 
very perceptible manner, and we could easily introduce the extremity of the finger into it. 
It is also at this period that the body of the uterus enlarges, which increases the size of the 
woman, and adds much to her bulk ; the touch or ballottement begins to lose its elasticity, 
the size of the head of the child no longer permitting it to be displaced with the same facility : 
but this circumstance only tends to render still more evident the pregnancy of which it serves 
to determine the advanced state. 

During the whole eight months, and, above all, towards the end, the fundus of the uterus 

* See fig. 2, Table IV. t See our Remarks, Plate IV. fig. 2. 

} Vide Table V, fig. 2. 



occupies the greater part of the epigastric region, its bulk is considerably enlarged, and its 
shape becomes more and more rounded and spherical. 

The umbilicus is distended and swollen, the neck loses more and more of its length and 
of its hardness, it is become soft, swollen above all towards the anterior lip.* 

The head of the child is large and heavy, the finger raises it with difficulty, and the bal- 
lottement can be no longer executed. 

At the end of the ninth month, and consequently of pregnancy, the fundus of the uterus, 
far from rising more and more, as we might suppose, falls lower than it was at the end of the 
eighth month ; we find it near the umbilical region. The cervix uteri is totally effaced, and 
it no longer presents itself but under the shape of a soft roll or cushion. 

The head of the child becomes still larger and heavier, and, as it rests above the superior 
aperture of the pelvis, it is almost impossible to raise it by the touch or ballottement. 

Such is the short sketch of the changes which operate in the form, figure, and size of the 
uterus, during the whole course of pregnancy. 

Although we derive very considerable advantage from attending to the signs of the epochs 
of pregnancy which are afforded by the development of the uterus, yet none of them are in- 
fallible before the fifth or sixth month. 

An accurate knowledge of the changes which take place in the neck and body of the 
uterus will, with a careful history of the symptoms, unable us to distinguish pregnancy from 
ovarian dropsy, tympanitis, moles, polypi, &c. 



DESCRIPTION OF PLATE IV. 

Fig. 1 — Represents a profile view of the virgin female, to shew the form 
of the abdomen, breasts, &c. The chief points to be observed in this 
drawing are the form of the abdomen and breasts, and also the relative size 
and sitnation of the uterus. The line enclosing the letter A denotes the size 
and situation of the uterus, and the colored space marked B the course of 
the vagina. 

The uterus is situated in the cavity of the pelvis, betwixt the bladder and rectum, 
below the small intestines, and above the vagina, in the direction of the axis of the superior 
strait of the pelvis, and forms nearly a right angle with the axis of the vagina. The os uteri 
points backwards and downwards, and its anterior lip is lower than the posterior ; the direc- 
tion however will vary a little, as the bladder or rectum may be full or empty. 

*See f\™. 4. 



TABLE IV. 




3 Spra.lt del 



Wajfnsr 8s M * 



Fig m 2 — Represents the female in the third month of pregnancy. We are 
here to observe the increased size of the abdomen, breasts, and uterus, com- 
pared with fig. 1. A. The situation and dimensions of the uterus. B. The 
course of the vagina. 

At the end of the third month, the fundus uteri is on a level with the superior margin of 
the pubis. About the end of the 4th month, the uterus rises to the hypogastrium, and the 
spontaneous motions of the fetus are felt by the mother ; but some women never perceive 
them during the whole period of pregnancy, and others imagine they feel the movements of 
the child when there is no conception. 

At the end of the fifth month, the uterus touches the inferior boundary of the umbilical 
region, and the cervix uteri will, on examination, be found to be considerably shortened. 
(See fig. 2, Table V. in the Obstetric Tables.) 

At this period, the most certain sign of pregnancy is afforded by the touch or ballottement 
and auscultation ; the touch consists of the introduction of the finger into the vagina, and the 
application of the. other hand above the pubis ; the uterus will be felt enlarged, and, if a 
gentle percussion be applied above the pubis, the fetus will be made to strike the finger, which 
cannot take place unless there be a fetus and fluid in the uterus. 

Fig. 3. — This figure represents the female at the full period of six months ; 
the enlarged size of the abdomen and uterus, (marked A.) are very conspicu- 
ous ; the breast is also more prominent, and the nipple elongated. 

At this period of gestation, we may call to our assistance auscultation, to enable us to 
decide if our patient be pregnant. The application of the stethoscope to the abdomen has 
been considered by some* as one of the most infallible proofs. M. Le Jumeau de Kergaradic 
has applied the ear and stethoscope to the abdomen, and discovered the double motion of the 
fetal heart, and also the pulsation of the placenta, which was synchronous with the maternal 
pulse. 

Morgagni proposes the following plan for discovering the motion of the foetus : — In warm 
weather, let the hand be immersed in cold water, and suddenly applied to the abdomen of the 
female ; and, in cold weather, let the hand be immersed in warm water and applied, when the 
motions of the child will be distinctly felt. Dr. Ryan says, " I have often acted on these 
suggestions with success."! 

At seven months, the abdomen affords a dull fluctuation, which differs 

* Dr. Kennedy, of the Dublin Lying-in Hospital, has written in favor of it. Dr. Ferguson, of Dublin, 
thinks it an unequivocal proof: see Dub. Med. Trans, vol. i, 1830. Dr. Elliotson is in favor of it. M. 
Velpeau has tried it in a number of cases without success; and Dr. Negle, of Dublin, thinks it equivocal. 

t Ryan's Manual of Midwifery, 3d edition, 1831. 



from ascites ; percussion affords a dull sound, which is distinguishable from tym- 
panitis or meteorism. At the end of eight months, the uterus has risen to the 
epigastrium, the cervix nearly obliterated, round, gaping, thickened, and pointing 
to the cavity of the sacrum. The limbs of the child may generally be felt through 
the parietes of the abdomen. 

Fig. 4. — Represents the female at the full period of gestation, (9 months). 
The uterus is now fully developed, the abdomen greatly distended, the cuticle, 
from the great distension, appears smooth and polished ; the breast firm and full, 
and the nipple elongated ; the umbilicus projecting, the cervix uteri is obliterated, 
and the orifice directed towards the sacrum. 

Fig. 5. — On raising fig. 5, the full-grown fostus is seen in utero, presenting 
in the natural position. 



TAB LE 1 B. 




G. Spralt del 



mfajniT i r iiuk\ 



an litti 



T AB LE 1 B. 



kw 



TABLE I. B. 

Fig. 1. — Front view of a perfect and well-formed female pelvis, the liga- 
ments being removed. 

The adult pelvis consists of four bones ; viz. the two ossa innominata, the os sacrum, and 
the os coccygis. The ossa innominata forms the sides and front of the pelvis. The os sacrum 
the posterior part (the upper and projecting part of which is called its promontory). The os 
coccygis is the small bone at the apex or extremity of the sacrum, consisting of three or four 
irregularly shaped pieces, united to the sacrum by an intervening nbro-cartilage, admitting of 
considerable motion during parturition. This union of the os coccygis to the os sacrum allows 
the former to recede, in most women, nearly one inch, as the head of the child passes the 
outlet. The other bones of the pelvis are united by various ligaments and cartilages ; and, 
there being no motion, the union is termed synarthrosis. 

Fig. 2. — View of the same pelvis resting on the left ilium. (This view is 
intended to give a correct idea of the position of the pelvis, when a woman is 
lying in a recumbent posture on her left side.) 

Fig. 3 — Represents a section of the bones of the pelvis (the left side.) 
The dotted line from a to a shows the axis of the brim of the pelvis, the centre 
of which is where the dotted line crosses the line marked i. The curved dotted 
line, marked b b, denotes, at the point where it crosses the dotted line a k, the 
centre of the lower aperture. The dotted circle round the letter c shews the 
situation of the acetabulum; d, the foramen magnum ; e, the bones of the sa- 
crum and coccyx ; /, the pubis ; g, the ilium ; A, the ischium. 

Fig. 4. — Horizontal view of the same pelvis. (This is intended to repre- 
sent the position of the pelvis, when the female, in the act of parturition, is 
about to be delivered, when lying on her back.) 

The above figures are about half the size of the natural pelvis, the drawings 
being made on the scale of four-eighths of an inch. 

The bones of the pelvis claim the particular attention of the accoucheur, as, without a 
proper knowledge of them, no one can be a competent judge how to act in difficult cases, or 
6 



under particular circumstances. The perfect pelvis varies in size in different women : from 
the rim, the depth varies in some of its parts. It is from four and a half to five or six inches 
behind, from the top of the sacrum down to the coccyx ; from two and a half to three inches 
at the sides to the lower edge of the ischium ; and one and a half to two inches deep at the 
symphysis pubis. 

Three parts of the pelvis demand particular notice. The brim or superior aperture ; the 
outlet or inferior aperture ; and the cavity. 

Each aperture of the pelvis has two diameters, a long and a short one : in the upper 
aperture, the long diameter is from side to side (about five inches and a half) ; the short 
diameter is from sacrum to pubis (about four and a quarter, or four and a half), but occasionally 
much wider. The lower aperture differs from the upper, in having the long diameter from the 
apex of the os coccygis to the pubis ; the short diameter is from ischium to ischium. 

The pelvis may be properly divided into two cavities or chambers, the upper and the 
lower. The axis of the upper chamber differs from the lower. The dotted line a a, Fig. 3, 
from the coccyx to the scrobiculus cordis (the part between the navel and pit of the stomach), 
represents the axis of the upper chamber, and shews the direction the forceps ought to take, 
when it becomes necessary to apply them, when only half the head of the child has entered 
the brim, and to draw downward and backward. But when the head gets lower down, so as 
to be chiefly in the lower chamber, the axis varies ; the forceps will then take a different 
direction, and continue changing as the head of the child advances in the direction of the 
central curved dotted line b b, Fig. 3, when the action of the forceps will be downward and 
forward. In all manual operations, the direction of the axis of the pelvis at its different parts 
must be accurately observed. " Even in bringing the foetal body through the pelvis, the course 
of the axis must not be forgotten, more especially if the pelvis be contracted."* 

It must be remembered, however, that the cavity of the pelvis is considerably diminished 
by its teguments and contents. Correspondent, however, to this diminution of the cavity of 
the pelvis, the head of the full-grown foetus measures but three inches and a half from ear to 
ear (the short diameter of the foetal head), and four and a quarter from the fore to the hind 
head (the long diameter). These dimensions, however, it must be recollected, differ both 
with regard to the pelvis and the foetal head, and are frequently the cause of lingering labors. 

* Dr. Blundell's Lectures. 






TABLE II B. 



Fi 9 / & 2 





G. Spratf del. 



^ WMpI ft Mt Omfaa i no 



TABLE II. B. 

Fig. 1 — Represents lines of Fig. 1 in the preceding Tables; a a, ossa ilii; 
6, os sacrum ; c c, ossa ischii ; d, os coccygis ; c, the lowermost vertebra; lum- 
borum ; //, ossa pubes ; g g, spinous processes of the ossa ischii ; h h, aceta- 
bula ; i i, foramen magnum. 

Fig. 2 — Represents the head of the fetus, in the first position, passing 
diagonally through the brim of the pelvis. On raising Fig. 2, the fetal head is 
seen presenting in the third position.* 

In an ordinary labor, the head of the child presenting, the vertex lies over the centre of 
the pelvis ; in the commencement of the process the face lies to one side of the pelvis, and 
the occiput to the other side ; hence the long diameter of the head corresponds with the long 
diameter of the pelvis (Fig. 1.); in this position, should there be no disproportion betwixt 
the head and the brim of the pelvis, the head very readily descends ; sometimes, however, 
the head of the child is placed with the face towards the pubes, and then the long diameter 
of the head is opposed to the short diameter of the brim or superior aperture (Fig. 2), and 
consequently the head passes with great difficulty. If the head be large and the pelvis small, 
it cannot pass, and it may be required to open the head. (See Tab. VII. B.) 

The head of the infant commonly passes into the cavity of the pelvis before the position 
is correctly ascertained ; the obstetricians who are well acquainted with the anatomy of the 
parts, and the divisions of the infant's head (sutures and fontanelles), will often be able to 
distinguish the direction of the head early in labor. When the head has passed through the 
rim of the pelvis, there is more space between the forehead and the pelvis than between the 
occiput and the pelvis ; the occiput being so prominent, a finger cannot pass between it and 
the pelvis. Should the head enter the pelvis with the forehead to one side, and the occiput 
to the other, instead of coming diagonally (see the third position of the head in this drawing), 
it may lodge before the spines of the ischia : there will then be considerable space between 
the side of the head and the symphysis pubis. By feeling the ear nearly opposite the 
symphysis pubis, and observing on which side the cartilage of the ear is, it will be known 
where the occiput lies. This mal-position may sometimes be changed to the diagonal direc- 
tion, by the application of two fingers on the temples, pressing the head a little upwards, and 
the face round towards the sacrumf: should this not succeed, it may be requisite to employ 
the forceps. 

* Maygrier, D. Davis, &c. &c. t Smellie, Clark, Conquest, Hogben, and others. 



Fig. 3. — Outline of Fig. 4 in Table I. ; a a, ossa ilii ; b, os sacrum ; c c, 
ossa ischii ; d, os coccygis ; e, the lowermost vertebrae lumborum ; ff, ossa 
pubes ; g g, spinous processes of the ossa ischii ; h h, acetabula ; i i, foramen 
magnum. 

Fig. 4 — Represents the head of the foetus passing through the lower aper- 
ture or outlet of the pelvis. The vertex towards the pubes and the face lying 
towards the hollow of the sacrum. 



Towards the end of the second stage of labor, and when the occiput is about to emerge 
from under the arch of the pubis, and begins to protrude through the os externum, the 
accoucheur should place his hand, covered by a soft napkin, in such a manner as to afford a 
regular and equal support to the perinceum, and guard it from laceration. The head must be 
prevented from passing over the perinaeum until it has acquired sufficient dilatability ; nor 
must it be allowed to pass suddenly over it, even when it is considerably relaxed, or laceration 
may take place. 

Fig. 5. — Outlines of Fig. 2, Table I. ; a a, ossa ilii ; 6, os sacrum ; c c, ossa 
ischii ; d, os coccygis ; e, the lowermost vertebrae lumborum ; ff 9 ossa pubes ; 
g g, spinous processes of the ossa ischii ; h h, acetabula ; i i, foramen magnum. 



TABLE III. B 



Eg 2 



Fi# / 




Fu, 4 





Fi# 6 



Fi<? J. 





vpratt do! 



/ wayiiif a w 



"ouiyan rmr-v 



TABLE III. B. 

Fig. 1. — Front view of the pelvis somewhat distorted. When the distortion 
of the bones is not more than in the pelvis here represented, and the head of the 
child of a moderate size, it may pass by the natural efforts ; but if not, the for- 
ceps or vectis (if judiciously applied) may succeed. 

Fig. 2. — Outlines of the same pelvis ; a a a a, the lowermost vertebra ; b, 
the sacrum ; c, coccygis ; d c?, ilium ; e e, ischium ; f f, tuberosity of ischium ; 
g, pubis ; h h, acetabulum ; i i, spinous process of ischium. 

Fig. 3. — A very remarkable distorted pelvis, occasioned by the disease term- 
ed mollities ossium. The distance from the most projecting part of the spine to 
the part where the pubes and ilium unite, measured on the left side only one inch 
and three-eighths, on the right side one inch. From the internal point of the os 
pubis on the right side to the centre of the vertebrae one inch and three-eighths, 
on the left side one inch and a half. 

Fig. 4. — Outlines of the same pelvis. 

The Caesarean section was performed by the late Mr. Hunter, on the body of Elizabeth 
Foster, aged thirty-six, from whose pelvis this drawing was taken. She expired twenty-six 
hours after the operation ; the child was preserved alive. This woman had borne several 
children previous to her being affected with this disease (mollities ossium). At the time she 
married she was perfectly straight, and measured five feet four inches high ; but, previous to 
her death, her stature was diminished one foot. 

Fig. 5. — View of another greatly distorted pelvis. The distance between 
the symphysis pubis and the projection of the sacrum measured only seven- 
eighths of an inch. From the termination of the coccyx to the lower part of 
the symphysis pubis one inch and seven- eighths. 

This drawing was from a model of the pelvis taken out of the body of Mary Rhodes, 
aged twenty-three years, on whom the Caesarean operation had been performed by Mr. 
Thompson, of the London Hospital, October 21, 1769. She expired five hours after the 
operation. This pelvis is not deformed like that of Elizabeth Foster's, nor from the same 
cause ; Mary Rhodes' was much deformed by rickets, being only four feet four inches high, 
her back very hollow, her hips narrow, and lower extremities crooked. 

Fig. 6. — Outlines of the same pelvis. 

Contraction or distortion of the pelvis occurs in every variety of degree ; the slighter 
contractions not unfrequently occasion protracted labors of various duration ; but the higher 
degree of contractions, requiring the use of the perforater, are fortunately rare. 

7 



These drawings of distorted pelves were made from casts (from the original skeletons) on 
the scale of one-third. By comparing these with the perfect pelvis, Table I. (which is made 
on the scale of four-eighths to the inch), the degree and peculiarity of the distortion will be 
readily discerned. 

The female pelvis is much more susceptible of injuries from pressures than the male ; the 
former being wider and more shallow in its cavity, and the bones more slender, to render it 
conducive to the easy passage of the infant. A distorted female pelvis is liable to be attended 
with most alarming consequences. There are two general causes for diseased bones in 
children : the one, and to which children very early are liable, is rachites (or rickets) ; the 
other, termed mollities ossium (a softness of the bones), a malady which may occur at any 
period of life. From either of these causes the pelvis is liable to become deformed. If the 
vertebral column become deformed after a person attains the age of puberty, without any 
appearance of the disease, mollities ossium, that is no proof of the pelvis being deformed. But, 
where the lower extremities are deformed, the pelvis is ever to be suspected of being deformed 
also ; and, in women whose stature does not much exceed three feet, there can be but little 
doubt that the pelvis is deformed. 

There is no great difficulty in determining the dimensions of the pelvis by the fingers in 
the vagina ; but not so readily the size of the child's head in the uterus.* 

To ascertain the distortion between the front and the back of the pelvis, let the fore-finger 
be placed on the promontory of the sacrum, and the rest of the fingers at the arch of the 
pubes, which will give the distance. To measure the brim from side to side, introduce all the 
fingers close together, and then, spreading them from one side to the other, the degree of 
distortion may be ascertained ; or all the fingers may be applied to the back of the symphysis 
pubis. If there be want of room behind the pubis, you will then feel something of an angle 
there. If the brim be of full measure from side to side, when all the fingers are introduced 
and placed behind the symphysis, they will all of them lie in the same place. 

To measure the outlet of the pelvis from before backwards, place the fingers so that the 
root of the index one lies against the arch of the pubes, and the tip of it upon the coccyx. 
Thus ascertaining the measure between the front and back, and by laying all the four fingers 
into the arch of the pubes, the distance from side to side may be known, t 

Those contractions which create the most frequent difficulties, and which at the bed-side, 
are found the most frequently to require the use of instruments, are almost invariably found at 
the brim of the pelvis ; therefore, whenever it is suspected that there is such a degree of 
distortion as may require the use of the forceps, lever, or perforater, the brim is the part of 
that pelvis which should be first and most carefully examined. When contractions occur at 
the brim, they are found almost invariably between the pubis and sacrum. The contractions 
lying at the brim are sometimes placed between one and the other side, where they rarely 
require the use of instruments. 

When the pelvis is known to be distorted to a considerable degree, so that an infant at its 
full time would endanger the life of the mother, and certainly could not be born alive, under 
such circumstances it may be advisable to attempt premature delivery at about the seventh or 
eighth month, as at that age it may be possible for the infant to pass, be born alive, and reared 
to maturity. 

* Foreign practitioners have invented a variety of different instruments, called pclccmitcrs for 
measuring the dimensions of the pelvis ; but British obstetricians consider them useless, 
t Blundell's Lectures. 



TABLE IV. B. 



Fitf. 1 




Fitf. 2. 




' 






&..Spia 



oner ft M c Guum J ah 



TABLE IV. B. 

Fig. 1 — Represents (of the natural size) a front view of the unimpregnated 
uterus and its appendages, with a section of the upper part of the vagina, the 
anterior part of which is removed to shew the collum uteri suspended in it. a, 
the corpus (or body) ; b, the cervix (or neck) ; these being raised show the cav- 
ity of the uteris i ; the dotted part h represents a section of the body, fundus, 
and neck of the uterus ; c, the ovaries on each side ; e?, the Fallopian tubes ; e, 
the fimbriae ; f 9 the round ligaments ; g 9 the broad ligaments. The ovaries, 
Fallopian tubes, &c. are raised a little out of their natural situation in order to 
display them the better, k, the cavity of the vagina ; /, the cut edge of the 
substance of the vagina. 

Fig. 2. — This figure represents the upper portion of the vagina, and the 
lower part of the body of the uterus and cervix uteri, the anterior part of the 
vagina being removed to show the cervix uteri, as shortened by pregnancy, 
about the length it commonly appears at the third or fourth month of gestation. 
a a shows the lower part of the body of the uterus as it is stretched at the same 
period. By comparing this figure with the unimpregnated uterus, Fig. 1, the 
alteration in the form of the parts will be readily perceived. Fig. b shows the 
cervix uteri at about the sixth month of pregnancy ; and c c, the body of the 
uterus at the same period ; Fig. d, the cervix uteri at the full term of gestation ; 
and e e, the uterus, stretched at the same period, which shows that the cervix 
uteri becomes nearly obliterated at the end of pregnancy. 

Considerable allowance, however, must be made in our calculations for the difference in 
the length of the cervix uteri in different women. In general, if the neck of the uterus be 
only half its usual length (the cervix uteri in the unimpregnated uterus being somewhat more 
than an inch in length), we may judge the woman to be between five and six months 
advanced in her pregnancy ; if three-quarters gone, between seven and eight months. At 

* A Description of the Uterus and its Appendages is given in Table III, illustrating the female organs 
of generation. 



this period, the uterus leaning forward over the pubes, the neck is thrown back towards the 
sacrum, and renders it difficult to reach the os tincae with the finger. 

The mode of ascertaining pregnancy, by examination per vaginam, by those who have 
habituated themselves, may sometimes be pretty correct ; but the prudent accoucheur will be 
cautious in giving his opinion until about the fourth or fifth month.* 

To examine well, it is necessary to carry the fingers very far into the pelvis : to do this, 
the finger must be placed in the front of the pelvis where the bones are shallow, and not on 
the back and sides where the pelvis is deep. 

It may happen that the uterus may become enlarged by disease, in which case, unless 
particular symptoms are attended to and minutely investigated, the accoucheur will be 
mistaken in his prognostic. 

The os tineas in the virgin state appears like a crevice or cleft going from side to side, and 
closed ; but in those who have had children it is circular, somewhat like a funnel with the 
large end downwards, into which the point of the finger may be introduced a little way. 
When the uterus is unimpregnated, the division between the neck and fundus cannot be 
distinguished, because it forms so very obtuse an angle ; but, if the womb be impregnated, 
the fundus will be enlarged to the size of an orange at the end of three months. (See Fig. 1, 
a a.) The best way of examining will therefore be, before you carry the finger to the os 
uteri, to pass it up the side of the vagina (to the upper part), and feel for the fundus. 

* Vide Denman's Introduction, &c. p. 202. 



% / 










VVdjner a M' T'uitfan h(K. 



TABLE V. 

Fig. 1 — Represents the back of the uterus and its appendages in the second 
month of utero-gestation, with a longitudinal incision down the posterior surface, 
crossed by a transverse one parallel to the entry of the Fallopian tubes, to shew 
the ovum, a, the right Fallopian tube ; b, the left ditto ; c, the decidua uteri, or 
decidua vera ; d, the decidua reflexa, or ovuli, covering the unattached part of 
the ovum ; c, the decidua vera, or uteri, passing down between the ovum and 
uterus ; f, the chorion ; g, the amnion ; A, the decidua lying between the cho- 
rion and decidua which crossed the cervix uteri. This drawing is half the size 
of nature ; for which, and the following description, we are indebted to Dr. 
Robert Lee, who kindly permitted us to copy his drawing, illustrating his remarks 
on the structure and formation of the human ovum, published in the 17th vol. of 
the Medico-Chirurgical Transactions. 

"Intervening between the superior and unattached surface of the ovum and fundus uteri 
was a broad but shallow cavity, measuring three inches in the lateral, and one inch and a half 
in the antero-posterior diameter, and from one to two lines in depth. The upper concave 
surface of the cavity, formed by the decidua lining the fundus uteri or decidua vera, was 
irregular and slightly reticulated. The inferior convex surface, formed by the decidua 
covering the ovum or decidua reflexa, was perfectly smooth, resembling the external serous 
surface of the uterus. Into this cavity the Fallopian tubes freely opened by palpable orifices ; 
that on the left side, by which the ovum had entered the uterus, being rather more than a line 
in diameter, that in the right rather less. The cavity thus formed between the decidua lining 
the fundus uteri and the decidua covering the upper and unattached portion of the ovum, was 
filled with a red-colored serous fluid." 

Fig. 2. — This figure is half the size of nature, and represents the back 
of an impregnated uterus, with a section of its body, to shew the foetus be- 
tween the third and fourth month of gestation.* The child is seen through the 

* At this period the uterus is liable to that displacement named retroversio uteri, which is most 
commonly occasioned by over distension of the bladder. The treatment of this accident consists chiefly 
in the regular employment of the catheter ; the bladder must be emptied twice in every twenty-four 
hours, until the uterus by its growth rises above the pelvis. 
7 






transparent membranes; the decidua reflexa, covering the transparent mem- 
brane, is represented by the opaque and white strise. The blue vessels repre- 
sent a convoluted vein, and the red convoluted arteries, a, the body of the 
uterus ; 6, the neck ; c, the ovaries ; d, the tubes ; e, part of the broad liga- 
ments ; f, part of the round ligament. The vagina is represented cut open, to 
shew the neck of the womb, &c. g 9 the upper part of the vagina, which is 
smooth and less rugous than the fore part ; /*, the orifice of the urethra ; i i, 
the nymphse ; k, the clitoris. 

Fig. 3 — Represents a section of the uterus and ligaments, with the right 
Fallopian tube containing an extra-uterine conception. 

Extra-uterine conceptions are mysterious deviations from the ordinary course of nature : 
no rational cause has yet been assigned for these occasional deviations. In most of these 
cases, the woman has sunk from the constitutional disturbance ; in others, after many years, 
an abscess has been formed, and bursting externally through some part of the abdomen, or 
internally into the large intestines, through which the various bones of the infant have been 
expelled. The uterus always becomes more or less developed, and secretes its decidua, 
during extra-uterine conception ; and the usual evidences of pregnancy are present. 

Fig. 4 — Represents an isolated ovarium. 

Fig. 5. — A section of an ovarium, in which is seen the vesiculse Graafian^, 
which contains the ovum or germ. 



TABLE VI. 



Fig. 1 — Represents a section of the left side of the female pelvis, with its 
contents, the upper portion of the left thigh, nates, &c. The uterus at the full 
period of gestation before labor has commenced, the os tincae not dilated, the 
finger in the vagina in the act of an examination, a, the left thigh ; b, the cut 
edge of the uterus ; c, the vagina ; d, section of the abdominal muscles, &c. ; 
e, the rectum ; /, the perinoBum ; g, the bladder ; h, section of the pubis ; i, k, 
section of the lower lumbar vertebra, sacrum, and coccygis. 



Ik 



■ 



TABLE VI 






4 ■■ 









M 



-,■: 




^s 



C . Spratt del 



Wa^er 4 M c Guijan lifK. 



V.-m 






When the finger is introduced through the os externum into the vagina, it should be 
passed upward and backward to feel for the os uteri, which, at the commencement of labor, 
will usually be found high up, and pointing backward (towards the sacrum) ; the touch of the 
finger will discover if the os tincse be open, and how much, and if the membranes be pressing 
down and distending it. The os uteri will in some instances be somewhat relaxed and open for 
several days, or perhaps weeks, previous to the accession of labor ; hence a slight dilatation of 
the os uteri is no proof that labor has commenced. If the os uteri be closed (as here repre- 
sented), and some length of the cervix remain, labor cannot have commenced, although the 
woman may have pains periodical in their return. These are denominated false pains.* 
But if there should be pressure upon, or dilatation of the os uteri during the continuance of 
the pain, we may be persuaded labor has commenced. When the pain is off, carry the 
finger upwards and towards the symphysis pubis, when the head of the child, if presenting, 
may generally be perceived by the resistance made to the point of the fingers. 

In some instances the os uteri is displaced and tilted backward towards the sacrum, 
so that it cannot be reached by the finger in the early part of labor. This situation of the os 
uteri occasions some embarrassment to young practitioners, who, upon a first examination, 
imagine the pelvis filled up by the head of the child, and hence anticipate a speedy delivery ; 
but, after the lapse of many hours, another and more accurate examination discovers the os 
uteri scarcely within reach (projecting towards the sacrum), and very little dilated. Labor, 
rendered tedious by this circumstance, requires only time and patience. 

Fig. 2 — Represents the same parts, with the os uteri considerably dilated 
in the time of a pain, the membranes containing the waters protruding, with the 
•index and middle finger of the left hand in the vagina. 

When the os uteri lies very high up in the vagina, we have found it more readily reached 
by the middle finger of the left hand than by the index of the right. 

When the os uteri is dilated to about one inch in diameter, the head presenting, the parts 
well formed, and the woman having had children, the labor may be considered in some 
forwardness, provided the pains be considerable. But should the membranes be ruptured at 
this period, either accidentally or intentionally, the labor would be protracted, and probably 
rendered very tedious, particularly if the os uteri should be disposed to be rigid. Hence, in 
making an examination, care should be taken not to press forcibly upon the membranes 
during the continuance of a pain. f 

We are told by Dr. Merriman, " It may be safely laid down as a rule (which will admit 
of very few exceptions), that the membranes should not be artificially ruptured, 1, while the 
head of the fuitus, or a large portion of it, is above the brim of the pelvis ; 2, while the os 
uteri is undilated, or in a state of rigidity; 3, while the iperinceum is thick and firm, or 
rigid."| 









Fig, 3 — Represents the same section of the parts, with a view of the os 
Uteri fully dilated, the membranes (containing the waters) protruding. 



* Denman's Introduction to Midwifery, sec. iv, p. 276. 
I Vide Synopsis of Difficult Parturition. 



t Ibid. p. 282. 



When the os uteri is fully dilated (as here represented), the membranes usually break 
spontaneously. Should the presenting part of the child not have been previously ascertained, 
it is no proof against its being a natural labor ; but should not the head or other part of the 
child be discovered by the finger after a pain or two (the membranes being ruptured), it will 
be justifiable to introduce the hand into the uterus to ascertain the presentation, and then to 
act according to the circumstances of the case. 

Fig. 4 — Represents the same section of the parts, with the left side of the 
uterus removed to show the child in the act of parturition at the termination of 
nine months' gestation. The head is represented here as advanced into the 
brim of the pelvis diagonally, with one ear inclined towards the right groin, and 
the other towards the junction of the sacrum and ilium, the most favorable 
position for its passing through the upper chamber of the pelvis, the long axis 
of the head being in the direction of the long axis of the pelvis. On turning 
down the section of this figure, marked A, the farther advancement of the head 
towards delivery is delineated. 

Fig. B, C, D, and E, illustrate the various turns of the foetal head after 
its entrance into the lower chamber of the pelvis, to its complete liberation from 
the os externum ; the dotted lines shewing the axis of the pelvis and vagina. 

When the head presses on and distends the perinaeum, as in Fig. C, then it will be 
necessary to apply the hand close over the perinaeum, to support it, and to check the 
advancement of the head when the forcing is very great, until the perinaeum is sufficiently 
stretched for the head to pass without its causing laceration. Laceration more frequently 
occurs from want of due caution in supporting the perinaeum at this period of labor, than 
from any other cause. The head being liberated from the os externum {Fig. D), ought not 
to be hastily dragged farther, but suffered to remain for another pain or two, which will 
generally be sufficient to expel the shoulders and body. When the head only is delivered, 
and the action of the uterus returns, care must be taken to support the head as it advances, 
and to direct it upwards to the abdomen of the mother (Fig. E), so that it may have a curve, 
accommodating to the ^..lection of the vagina, and illustrated by the dotted lines. 

To ascertain, fro^ commencement of the natural labor, how long it may continue 

before the child is .ed (even in those who have had children, and the pelvis well- 

formed,) must in a great measure be uncertain, as much will depend upon the degree of 
ossification of the cranium and on the size of the child; perhaps, in the general run, it may 
be calculated that, from the time of the commencement of the pain till the membranes break, 
eight hours may elapse ; after which, if the head pass immediately into the upper chamber 
of the pelvis, the pains being strong, the vagina and the os externum properly relaxed, the 
child will be delivered in one hour, or sooner ; but if the head be very large, it may be two, 
three, four, or more hours ; and when the child is small, it may be born two or three pains 
after the membranes rupture. In cases of a first child, it seldom happens that it is delivered 
in less than twelve hours, even if the child be small. 



Generally, in fifteen or thirty minutes from the expulsion of the child, the woman com- 
plains of a slight pain in her back and abdomen ; and this secondary contraction of the uterus 
detaches the placenta, and usually expels it through the passages. 

Sometimes the placenta is retained beyond the usual period for its expulsion. 1st, from 
inaction or insufficient action of the uterus. 2dly, by the irregular action of the uterus. 
3dly, by the adhesion of the placenta to the uterus. Though the placenta be retained after 
the birth of the child, if there be no hemorrhage or other untoward symptom to demand imme- 
diate interference, we are to wait in expectation of the uterus acting. Should the placenta be 
retained in utero, in consequence of insufficient power, on an external examination of the 
abdomen, instead of communicating to the hand the sensation of a hard ball, just above the 
symphysis pubis, it will be found large and loose, occupying a considerable part of the cavity 
of the abdomen ; the management of this case is to produce uterine contraction ; and it is to 
be accomplished by external and internal means ; the former is by the steady employment of 
pressure on the abdomen with a bandage, or by grasping the uterus within the palm of the 
hand, briskly rubbing the uterine region and loins, or dashing the abdomen with cold water. 
The internal means to be employed are introducing the hand within the cavity, and gently 
moving the fingers until the contractile power of the uterus returns and expels the hand and 
placenta; cold water may also be injected. For the management of the placenta, when 
detained from irregular contraction or adhesion, see Table v. B. 

Labors rendered difficult or protracted from, defective parturient Power or preternatural 

Resistance. 

Any circumstance debilitating the constitution or the uterus will produce feeble or irregular 
uterine action. When parturition is protracted from this cause, the powers of the system must 
be supported by nutritious diet ; no voluntary exertion or forcible straining should be permit- 
ted. Uterine action may be increased, by friction of the abdomen and loins steadily employed, 
and moderate pressure on the abdomen, and a mild tepid enema. Opium is a very efficient 
remedy, and may be given either by the mouth or rectum, to the extent of twenty minims, 
so as to procure sleep and suppress the irregular action of the uterus, that on their recurrence 
it may act with greater energy. The ergot of rye has been given with great advantage in 
these and other cases dependent upon an enfeebled condition of the uterus.* 

* The ergot may be advantageously given under the following circumstances. When the child has 
descended into the pelvis, the parts dilated are relaxed, the pains having ceased, or being too ineffectual 
to advance the labor, there is danger to be apprehended from delay, from hemorrhage, or other alarming 
symptoms : 

When the pains are transferred from the uterus to other parts of the body, or to the whole muscular 
system, producing puerperal convulsions : 

When the placenta is detained from a deficiency of contraction, when local discharges or hemorrhages 
are too profuse immediately after delivery, and the uterus continues dilated and relaxed without any 
ability to contract : 

In patients liable to hemorrhage immediately after delivery, in such cases, the ergot may be given as 
a preventive, a few minutes before the termination of the labor. When, in the early stages of preg- 
nancy, abortion becomes inevitable, accompanied with profuse hemorrhage and feeble uterine contractions : 

When judiciously administered under the above circumstances, the ergot is very efficacious, being 
8 



If plethora, as indicated by the force or frequency of the circulation, produces this irregu- 
lar and feeble action, the detraction of a few ounces of blood will accelerate the labor. 
Rigidity of the os and cervix utere is another cause of very lingering labor ; time will usually 
terminate these ; yet abstraction of blood, regulated by the powers of the constitution, freely 
opening the bowels by an aperient exhibited by the mouth, and an emollient glyster, will 
materially accelerate the dilatation. After which, one or two drachms of tincture of opium, 
with a few ounces of tepid water or gruel, may be thrown into the rectum. A drachm or 
two of the extract of belladonna gently rubbed on the os uteri will often speedily relax the rigid 
condition of it. All stimulants, exertion and fatigue, must be carefully avoided. When 
rigidity of the external parts retards the expulsion of the child, sufficient time must be given ; 
fomentations, and lard liberally introduced within the vagina, will promote the desired effect. 
Another cause of protraction, and which sometimes proves very tedious, is oedema of the 
cervix uteri, and must be relieved by cautiously elevating the fundus uteri, and dilating and 
supporting the os uteri during the paroxysms of pain ; artificial dilatation of the osdematous 
cervix uteri must not be persevered in, if it be acutely sensible. When this is the case, the 
abstraction of blood will be very beneficial. 

Mal-position of the uterus, in which the os uteri is either thrown backward against the 
promontory of the sacrum, or forward against the symphysis pubis, protracts labor. In these 
cases, nothing but time and patience will effect a change. Anchylosis of the os coccygis to 
the sacrum is another cause for which no relief, but such as time affords, can be given. 

Various other causes will produce lingering and protracted labor ; as, want of room, the 
pelvis being encroached upon by tumors of various kinds, as the cysts of ovarian dropsy, 
hernia of the bladder, &c. or the head of the child may be enlarged by hydrocephalus 
Should the cause of impediment be compressible and not very formidable, time and powerful 
parturient efforts may overcome it. Some tumors may be elevated and kept above the brim 
of the pelvis until the presenting part occupies the superior aperture of the pelvis. Some 
may be safely punctured, and others may require the forceps, perforation, or the scalpel ; but 
no invariable direction can be given for the management of these cases, as much must depend 
upon the size, consistence, and situation of the obstruction. 

followed, in from five to twenty minutes after its exhibition, by uterine action, which gradually increases, 
and goes on without any intermission till the delivery be completed. 

Twenty grains of ergot, given every ten minutes, answers better than a larger dose, as it is not so 
likely to affect the stomach with nausea or vomiting, which a larger dose is apt to do. 

The ergot should never be administered until the rigidity of the os uteri has subsided, and a perfect 
relaxation induced; nor should it ever be administered in any case of preternatural presentation that will 
require the child to be turned. 



TABLE VII 



y. 



Fio 1 & 2 



M 




Fitf . 3 




\V. 






\-/j; 




Tii .6 & 7. 



/ 




G Sprall de 



Waoner it m! Guioan lith. 



* *■ ' 






V 






TABLE VII. 

Fig. 1 — Represents a section of the pelvis, uterus, &c, to show a morbid 
enlargement of one of the ovaries, occupying nearly the whole cavity of the 
pelvis, and preventing the descent of the child's head, a, the bones of the 
lower part of the spine, sacrum, and coccyx ; b, section of the ossa pubes ; c, 
the bladder ; d, the rectum ; e, the vagina ; /", medulla spinalis ; g, muscles and 
integuments of the abdomen ; i, cut edge of the uterus ; k, the enlarged ovary. 

The most frequent cause of enlargement of the ovaries is the disease called encysted 
dropsy. References to eighteen cases may be found in the tenth volume of the " Medico- 
Chirurgical Transactions." These tumors have been found of various sizes and degrees of 
firmness ; hence it is obvious that tumors so situated must prove an obstacle to parturition in 
proportion to their bulk and compressibleness. In cases of very moderate or partial confine- 
ment of the pelvis from this cause, it will be prudent to trust to the efforts of nature* to expel 
the child ; and we are told by Dr. Merriman, that « where the tumor was not very large nor 
very firm, this method has been successful. In the more formidable cases of obstruction from 
this cause, various methods have been recommended to preserve one or both lives. With a 
view of preserving the child, some have recommended the operation of turning, but this does 
not appear to have been successful. Others have taught, that in such cases the perforator 
should be employed without delay. Sometimes the tumors have been opened, but in several 
instances it has been necessary subsequently to have recourse to embryotomy." In cases 
of moderate obstruction from this cause, the occasional use of the forceps may be 
expedient, to shorten the duration of labors, which might otherwise become dangerous to 
the mother or child. 

Dr. Merriman, after enumerating the different methods adopted in eighteen cases, says, 
" Upon the whole, the evidence we at present possess is more in favor of opening the tumors, 
when they contain a fluid, than of any other mode of procedure." 

Fig. 2. — This figure represents a displacement or protrusion of the urinary 
bladder, occasionally met with during labor, and which proves an impediment 
to the birth of the child. 

This protrusion consists in a descent into the cavity of the pelvis, of a portion (more or 
less) of the parietes of the distended bladder, which form an elastic tumor (as represented at 
h), situated either under the arch of the pubes, occupying the anterior part of the vagina, or on 

* See Davis's Operative Midwifery. 



one side.* The anterior protrusion is probably more frequently an obstacle to parturition than 
the lateral. We have met with one case of the. former, and Dr. D. Davis says he has met 
with several, but not with one of the latter. We are told by Mr. Christian, " as the tumor is 
covered by the vagina, and its base diffused, there can be no danger of its being mistaken for 
the membranes enclosing the liquor amnii, nor does it, indeed, prevent the os uteri from being 
readily felt. If an error of this kind is at all to be apprehended, it is where the tumor is 
situated under the arch of the pubes." Dr. Merriman relates a case of the anterior protrusion, 
which was unfortunately mistaken for the head of a foetus enlarged by hydrocephalus, and 
fatally punctured. Hence how much it behoves the inexperienced to pause and minutely 
examine every circumstance before they venture upon an operation. The remedial agent in 
these cases is the introduction of the catheter (to draw off the water), which will detect and 
cure this displacement. 

Fig. 3 — Represents a case of procidentia uteri, which forms a pendulous 
tumor, hanging between the thighs ; the bladder occupies and forms the 
anterior part of it. 

a a, the thighs ; b, the mons veneris ; c, the catheter ; d, the anterior portion 
of the tumor formed by the bladder ; on raising this part, the bladder is sup- 
posed to be laid open. 

In cases of procidentia uteri, when it becomes necessary to introduce the catheter to draw 
off the urine, we must bear in mind the unnatural course of the urethra — the catheter being 
introduced in the usual course till its point has reached the symphysis ; its handle must then be so 
elevated towards the abdomen, that the extremity of the instrument should be directed towards 
the knees, which is clearly shown at Fig. 2, representing the point of the catheter in the bladder. 

Fig. 4, 5, 6, and 7 — Represent sketches of face presentations. The letters 
refer to the same parts in all the four figures, a a, section of the lower part of 
the uterus ; b, the rectum ; c, the vagina ; e?, the left labia ; e, the left nymphae ; 
f, part of the bladder ; g, os pubis of the left side ; A, section of the bones of 
the sacrum and coccygis ; i, the perinaeum ; k, section of the muscles, &c, 
covering the bones of the sacrum, &c. 

Fig. 4. — Face presenting with the occiput to the left side. 
5. — Face presenting with the chin towards the pubis. 
6. — Face presenting with the occiput to the right side. 
7. — Face presenting with the chin towards the sacrum. 

Remarks on these presentations follow our description of Table IX. 

* See Dr. James Hamilton's Cases in Midwifery, p. 9 ; and Mr. Christian's paper in the Edinburgh 
Medical and Surgical Journal, vol. ix, p. 281. 



^ "*v 






PRELIMINARY OBSERVATIONS ON THE USE OF INSTRUMENTS. 



It has long been established as a general rule, that instruments are never to be used in 
the practice of midwifery, but from positive necessity. 

To determine the proper period for their employment, is one of the nicest points in the 
practice of obstetric art. The following general rules may be laid down. 

The forceps are used to supply, with them, the insufficiency or want of labor pains; but 
so long as the pains continue, and we have reason to hope they will be effectual, we shall be 
justified in waiting. 

The lower the head of the child has descended, the easier in general will their application 
be ; the success of the operation more certain, and the hazard of doing mischief less. 

The cessation or diminution of pain is either the consequence of original debility, or of an 
exhausted state of the uterus from long-continued exertions ; and must be distinguished from 
that temporary suspension of uterine action, which is not accompanied with any other 
unfavorable symptom, and which may be often removed by repose and nourishment. But 
should the pains have been for many hours strong and expulsive, and cease altogether, the 
presenting part firmly wedged in the pulvis, interrupting the functions of the bladder and 
rectum, accompanied with fever, restlessness, headache, vomiting, mental inquietude, 
abdominal tenderness, with heat, dryness, and pain about the vagina and os uteri (the os 
uteri being fully dilated), timely assistance must be given ; otherwise, exhaustion, sloughing, 
or other untoward symptoms terminating in death, will soon close the scene. 

Before using instruments, the rectum and bladder should, if possible, be always 
emptied. 

Instruments should always be introduced slowly and cautiously, and during the intervals 
of the pains ; and the assistance given with them should be afforded during pain (should 
there be any), in order that the uterus may be gradually emptied. 

The extracting power should be employed in the direction of the axis of that part of the 
pelvis at which the head is situated ; if it be at the brim, the handle of the instrument must 
be directed backward against the coccyx; but as the child advances, that part of the 
instrument grasped by the operator's hand should gradually be directed towards the pubes. 

The short forceps are used by most practitioners, and those constructed with reflecting or 
moveable handle are decidedly to be preferred. The long forceps may be substituted for the 
short ones in most cases ; but the blades must be fixed on the sides of the face, if the head be 
m the cavity of the pelvis ; but if the head be at the brim, over the occiput and forehead. 



Particular rules for applying the forceps in every position of the head are given in Tables viii. 
and ix. 

On the Application and Use of the Vectis. 

We shall have a just idea of the vectis, by considering it as one blade of the forceps, a 
little lengthened and enlarged, without any lateral curvature. The general condition and 
circumstances of labors, as requiring and allowing the use of the forceps, will hold equally 
good when the vectis is intended to be used. The vectis may be employed, subject to very 
much the same regulations as the forceps ; the advantages of the vectis are, that it may be 
used earlier, and can be applied to any part of the head. The vectis should be employed 
rather as a hook than a lever, and on that principle is a safe instrument ; but, if used on the 
lever principle, acting upon the soft parts of the mother as the fulcrum, a dangerous 
instrument, and much mischief has been done by its use. 



V 



TABLE VIII. 



,w 




G . Spraft de 



TABLE IX. 

Fig. 1 — Represents the same section of parts as in the preceding Tables, 
with a portion of the lower part of the uterus removed to shew the head of the 
child in the second position, viz., with the face towards the pubes. In this 
drawing the dotted lines are intended to represent the double curved forceps, 
and shew the different hold they have of the head compared with the common 
short forceps here represented as applied. 

This is the most frequent of all the wrong presentations of the head. In this position the 
head is usually longer in passing through the pelvis than in the first position ; but if the pelvis 
be well formed, and the action of the uterus strong, in the majority of cases the child will be 
expelled alive by the natural efforts. Should untoward symptoms arise, so as to demand 
artificial assistance, this position (when the head has descended low into the pelvis) may 
sometimes be rectified as proposed by Dr. Clarke, by laying two fingers on the cheek, and 
pressing gently during every pain, gradually turning the face into the hollow of the sacrum. 
Should this not succeed, the forceps or lever, or other means, must be resorted to, according 
to the exigencies of the case. In this presentation, if the lever be used, it may be applied 
over the mastoid process, in order to bring the chin below the pubes, when the case would 
be managed without much difficulty, and with little risk to the perinseum ; or the lever may 
be passed behind the occiput, to assist the pains in advancing the occiput towards the os 
externum. The application of the forceps in this position of the head does not materially 
differ from the first position, described Table VIII. They are to be applied over the ears of 
the child ; but when applied (as will be seen by the drawing) they have a different and less 
perfect hold ; hence they are more apt to slip, and act with less advantage. 

In this position, when the head is brought sufficiently low to distend the external parts, 
there will be great danger of laceration, unless the perinoeum is cautiously guarded, and the 
head prevented from advancing too fast (if the pains be strong), until die os externum is 
gradually and sufficiently dilated. 

Fig. 2. — In this drawing the right side of the uterus is removed to show 
the child in the act of parturition, with the face towards the right side of the 
pelvis (one ear to the sacrum, the other to the pubes); this may be denominated 
the third position of the foetal head. 



V 









TABLE IX 



-' .'■■• ' ''■'. 



: jffiH ', 



i -**>.- 





& M'. Guijan Ink. 



In this unfavorable position, the head is (especially if large, or the pelvis somewhat small) 
liable to become arrested in its progress through the pelvis. Should there be occasion to use 
the forceps in this presentation, they must be applied over the ears of the child ; but, to 
facilitate the expulsion of the head, it will be necessary to alter this position to the first or 
most natural position. This is to be effected by carrying the face into the hollow of the 
sacrum, by a gentle rotatory movement from left to right, to about one-fourth of a revo- 
lution, or what is called a quarter turn. The mal-position of the head being removed by this 
movement, it is probable the labor-pains (if there be any) may be sufficient to expel the fetus 
without further assistance. 



Fig. 3 — Represents the forceps applied in the fourth position of the foetal 
head, i. e. with the face to the left side of the pelvis. 

In this presentation the left ear may be felt behind the symphysis of the pubes ; the head 
being arrested in its progress by its untoward position, it becomes expedient to alter the 
position by turning the face into the hollow of the sacrum. This is to be effected by 
reversing the rotatory movement described in the preceding position of the head. In this case, 
the face being turned to the left side, the movement must be made from the right to the left. 
The head being in this manner placed in the most favorable position, nature will in the 
majority of cases accomplish the delivery without further assistance. Hence the forceps 
may be removed, unless hemorrhage or other untoward symptoms demand a more speedy 
delivery. 

Fig. 4. — The face in this drawing is represented as being carried into 
the hollow of the sacrum, by the rotatory movement described in the two 
preceding positions of the head ; the case now becomes similar to a natural 
presentation, and may be managed as such in every respect according to cir- 
cumstances. 

When the face presents, it may be known, by the inequality of the presenting part, and the 
distinction of the nose, chin, &c. The management of these cases must, in a great measure, 
be left to the efforts of nature, as the child may pass by the pains only, after a tedious labor. 
But the features of the face are often amazingly distorted, and it is well known that long and 
severe pressure on the head in such presentations often destroy the child in the birth. There- 
fore if assistance can be rendered either by the forceps or vectis to shorten the labor, so as 
to preserve the life of the child, the judicious use of such instruments must be acknowledged 
to be of real benefit. 

Should symptoms require the use of the forceps, they must be applied over the ears of 
the child (as represented in fig. 4 and 6, Table VII.), and, in acting with them, extract' from 
handle to handle, at the same time bringing the chin round to the symphysis pubis. Face 
presenting with the chin to the sacrum. (See fig. 7, Table VII.). Should the forceps be 
found necessary, from the size of the head, or from floodings, faintings, &c. they must be 



applied over the ears, ana the handles kept close against the perinceuin. In this presentation 
the vectis may also be applied, as we have represented a blade of the curved forceps, i. e. 
over the ear and mastoid process. Face presenting with the chin towards the symphysis 
pubis. (See fig. 5, Table VII.). This is the most favorable of the face presentations.* In 
this case the vectis, if judiciously applied over the occiput,! will alter the position of the 
head ; but should this not succeed, the forceps must be applied as in the former case. In 
general, when the face presents, it is more convenient to deliver with the vectis, or with one 
blade of the forceps, than with both blades. 

* Denman's Introduction to Midwifery. t Vide Hogben's Obstetric Studies. 



TABLE X. 

Fig. 1 — Represents the same section of the parts as described in Table 
VI., with a section of the uterus, the right side being removed to show the 
foetus in the act of parturition, the breech presenting with the back towards 
the fore part of the pelvis. The os uteri nearly dilated, the membranes 
broken, and the waters discharged, with the uterus contracted round the body 
of the child. 

This presentation forms one of the first order of preternatural presentations, which include, 
also, the presentation of the hip, the knees, or one or both legs. This presentation may 
generally be known, by distinguishing the anus and organs of generation, and by the escape 
of the meconium. In the nates presentation, if the pelvis be well formed, and the child not 
particularly large, children are usually expelled by the action of the uterus. It has been 
recommended by some writers, to assist the delivery, when the buttocks do not pass readily 
through the pelvis, (there being urgent necessity for hastening the delivery,) by passing a 
finger on each side over the thighs to the groins, or, when the groins are beyond reach of the 
fingers, to introduce the blunt hook, by which to extract the child ; or the descent of the 
nates may be assisted by the forceps, applied (one blade on each side) over the flank of the 
child.* There is yet another mode by which the nates may be extracted, which is by passing 
a fillet or silk handkerchief over the bend of the thighs, close to the belly ; by this the 
necessary extracting force may be very advantageously and more safely employed, than by 
the blunt hook.f When the nates are brought Jhrough the os externum, the case becomes a 

* Dr. Blundell's Lectures. t Vide Merriman's Synopsis. 



.V 



TABLE X 



: « 






. 







raft del 



Wajjner & M c Cruijjar 



crural presentation; and the direction of the toes, and all other circumstances requiring 
attention in presentations of the feet, must be attended to. 

Fig. 2 — Represents the child presenting with one hand and foot. 

This mixed presentation is very rarely met with, but we have introduced it to caution 
junior practitioners to avoid the error of mistaking a superior extremity for an inferior : this 
error has occurred. The crural or foot presentation is the most simple, and often the safest 
to the mother, of any of the preternatural presentations ; but the life of the child is often placed 
in considerable danger from the compression of the naval cord, after the body of the child has 
passed through the pelvis. Hence, so soon as the body is born, the object of the accoucheur 
is to facilitate the head through the pelvis with all convenient speed. In order to accomplish 
this, it becomes necessary that the head of the child should occupy the hollow of the sacrum, 
after it has passed the superior aperture of the pelvis. To ascertain the position of the head, 
we must examine the feet ; if the toes are turned towards either sacro-iliac synchondrosis, the 
foetus is already in the proper position, but if the toes point to the symphysis pubis, the head is 
then in an untoward position, because it cannot adapt itself to the form of the pelvis. It will 
therefore be proper, if the head be in a wrong position, so soon as the nates have passed 
through the os externum, to grasp the nates and thighs (previously wrapped in warm cloth, to 
prevent the fingers from slipping), and during a pain to give such an inclination to the child 
as will incline the face towards the sacrum.* The arms should then be cautiously brought 
down, one after the other ; the head is then to be extracted as expeditiously as the necessity 
of the case may need ; if the pulsation in the string become weak or cease, the case becomes 
urgent, and without waiting for natural pains, the extraction must be made ; but so long as 
a pulsation is felt there is no occasion for hurrying the delivery. 

Fig. 3 — Represents the presentation of the arm, which forms one of 
the second order of preternatural presentations, according to Denman and 
others. This order also includes the presentations of the shoulder, and the 
more rare presentations of the back, or belly, or sides.t 

In either of these presentations it is necessary to turn the child and deliver 
footling, it being impossible for a full-grown foetus to pass through the pelvis in 
either of the above positions. On the operation of turning, see Table VI. B. 
The necessity of turning in these presentations is universally admitted, and the 

* Vide Dr. Blnndell's Lectures. 

t Madame Boivin, in her Memorial de l'Art des Accouchemens, has given delineations of those 
positions ; but as. in 20.517 cases delivered at the Hospice de la Maternite at Paris, no instance of such 
presentation has occurred at the full period of gestation, we have not thought it necessary to swell the 
present work by delineating them. 






more speedily this is accomplished, when the os uteri is sufficiently dilated (either 
naturally or artificially, as the case may require) to admit the hand into the 
uterus, the more easily and safely will the operation be performed.* Having 
obtained room to pass the hand through the os uteri, rupture the membranes 
(should they not have been previously broke) by pressing a finger firmly against 
them, the hand will then come in contact with the limbs or body of the foetus. 
The hand is then to be carried forward till it reaches the feet, which should be 
carefully drawn down along the belly of the child, and as the feet are brought 
lower, the presenting arm will be retracted ; when the feet are brought through 
the os externum, the case becomes similar to a crural presentation, and must be 
managed as such. 

Fig. 4 — Represents a shoulder presentation ; the management of this case 
is by turning the child, as described in the preceding figure. 

Fig. 5 — Represents the foetus in the natural position, seen through the 
amnion and waters ; the funis presenting with the membranes unbroken. 

When the funis presents, the most usual part of the fetus beyond it will be found to be 
the head (as represented in the drawing), the nates or feet. Formerly it was supposed that, 
whenever the funis presented, the foetus lay across the pelvis, with the umbilicus over the os 
uteri ; and M. Magrier supposes the descent of the funis to indicate a presentation of the 
belly, f Smellie has also represented (in his plates) the descent of the funis as accompanied 
with the presentation of the abdomen ; but the presentation of the abdomen is extremely rare ; 
whereas presentations of the funis are by no means uncommon, and, when occurring, usually 
precede the head, nates, or foot. When the funis presents, the child's life is always in danger ; 
for if much pressure be continued on the funis for the space of a few seconds, the child 
becomes languid ; and if the circulation be suppressed for one minute, the child is in the 
utmost danger. Hence, attention must be paid to the pulsation of the funis. If, upon a first 
examination, no pulsation is to be felt in the funis, the child is already dead, and the case 
must be managed according to circumstances, without regard to the funis ; but if there be a 
pulsation in the cord, we are assured that the child is yet living. Various modes have been 
proposed by different practitioners for replacing the protruded cord, but not one of which is 
likely to succeed in every, or even in the majority of cases ; for the funis is generally forced 
down again on the pain returning.^ When the head is low down in the pelvis, it may be 

* In ordinary cases, if the os uteri be dilated to the size of a crown piece, and the soft parts in a state 
of relaxation, the sooner the operation is commenced the better. 

t Vide Methode pour manceuver les Accouchemens, 1804, p. 49. 

t Mr. Hogben (vide Obstetric Studies) recommends, after the funis has been carried as far as possible 
above the brim of the pelvis by the fingers or some other contrivance, to introduce a piece of sponge, so 
as to keep the funis from sinking. Dr. Davis (see Elements of Operative Midwifery) recommends fixing 



prudent sometimes to hasten the delivery (if the child be living) by means of the forceps. 
« If the breech present, it may be expedient to bring down one or both the inferior extremities 
at a proper time, taking care that the funis be not entangled between the legs of the infant." 
Should the upper extremities present with the funis, recourse must be had to turning, if the 
child be living or dead (the position of the child demanding the operation of turning inde- 
pendent of the funis). We would say, were we called to a case in which the os uteri was 
very considerably dilated, as represented in the drawing — the membranes unbroken — the funis 
pulsating strongly — the head beyond it — we would rupture the membranes, gently introduce 
the hand, and turn the foetus ; or should the membranes be broken, and our efforts to return 
the funis prove ineffectual, we would turn, provided the funis pulsated * and circumstances 
peculiarly favorable to turning, viz. the passages so relaxed and dilated as to admit of the 
easy introduction of the hand, and the pelvis capacious — if, on the contrary, the pulsation in 
the cord should have ceased, the case should be left to the efforts of nature. 

the funis by means of thread to the point of a thin, flat plate of elastic steel, fixed in a wooden handle, 
and carrying the point of the instrument above the head of the child, out of the way of pressure. Dr. 
Mackenzie succeeded by tying the prolapsed funis in a small leather bag, and carrying it beyond the head 
of the foetus. 

* Dr. Conquest very justly observes, " that all the advantage proposed to be gained (by turning) is on 
the part of the child, the mother's life not being endangered by a presentation of the funis; consequently, 
as the operation of turning is sometimes destructive to the mother, it ought never to be performed merely 
to save the life of the child." 



TABLE XI. 

Fig. 1. — The abdomen laid open to show a front view of the gravid uterus 
at the full period of pregnancy, a a a a, the peritoneum lining the parietes of 
the abdomen ; b, a portion of the omentum covering the small intestines ; c, part 
of the small intestines ; d d, the round ligaments of the womb ; e e, the fallopian 
tubes ; on the left side little more than the beginning of the tube is seen, the 
rest running down behind the womb: on the right side, the middle part only is 
exposed, the beginning being concealed by the intestine which lies upon that 
part, and the end or fimbriae being covered by the spermatic vessels. 

The fundus of the impregnated uterus at the period of between two and three months is 
even with the brim of the pelvis ; about the latter end of the third or fourth, but sometimes a 
little later, the uterus advances above the brim, and is then readily perceived by the hand 
through the abdominal muscles, &c. Between the fourth and fifth month the fundus is between 
the pelvis and the navel ; at the sixth, as high as the navel ; at the seventh month, between 
the navel and scrobiculus cordis ; in the eighth month, up to the scrobiculus cordis. The 
foetus, at the full period of utero-gestation, weighs on an average from six to nine pounds, the 
placenta little more than one. The liquor amnii varies so considerably, that it is difficult to 
form an average quantity ; but we may say that the quantity generally contained in the mem- 
brane is from eight ounces to sixteen. When it exceeds three or four pints, it may be consi- 
dered excessive, and is then frequently the cause of lingering labors, from -over distension of 
the uterus.* Cases are on record in which the liquor amnii has measured five and ten pints ; 
and when the foetus is diseased, the liquor amnii occasionally far exceeds the above quantity. 

In the early stages of gestation, the quantity is larger in proportion to the size of the uterus 
than afterwards. The liquor amnii is sometimes of a greenish cast, often of a milky appear- 
ance, and at other times of a yellowish color. It contains water, albumen, carbonate and 
muriate of soda, and phosphate of lime. 

The membranes of the ovum become of a firmer texture towards the end of pregnancy. 
Occasionally they are found, at the time of labor, unusually rigid and thick, and thus occa- 

\ 

* Should this case be very obvious, the membranes may be punctured, but the necessity for this very 
rarely occurs ; and certainly not until the membranes distended with fluid have fully performed their 
office of dilating the os uteri and the passage of the os externum. (Conquest.) 



\i: 



\i 
















































} 



i 



V 



& Sprait del 



Warner 8c M ! (hug an lit'h. 



sion a protracted delivery. Cases are on record in which the membranes have exceeded an 
eighth of an inch in thickness.* When the membranes have not been artificially ruptured, 
(and as a general rule of practice they never should be,) and have withstood the action of the 
uterus, the whole ovum has been expelled at once. 



Fig. 2. — The tunica decidua, a tender lacerable substance or membrane, 
secreted by the uterus, and forming the outer layer or coat of the ovum. In 
the earlier months of utero-gestation, it may be easily separated into two laminae : 
the one in contact with the uterus, named tunica decidua uteri ; and the other, 
from being reflected on the first (and covering the chorion), the tunica decidua 
reflexa. After the fourth or fifth month, these two lamina) become, as it were, 
identified, and no longer separable. 

Fig. 3. — The chorion, a dense, thin, smooth membrane, connected with the 
decidua as far as the edge of the placenta ; it is then reflected over the surface 
of the placenta, which is opposed to the fetus, and continued over the cord. 

Fig. 4. — The amnion, a thin, transparent dense membrane, lining the cho- 
rion (through which the fetuses are seen). The amnion is smooth and polished 
next the fetus, and destitute of vessels ; it encloses the fetus and liquor amnii, 
and assists in dilating the mouth of the uterus at the period of labor. 

Fig. 5 — Represents a plural conception, each fetus enveloped in separate 
membranes. 



Twin cases usually terminate with safety both to the parent and children. It is the duty 
of the accoucheur invariably to ascertain if there be a second child before leaving his patient. 
After the birth of one child, the existence of one or more remaining in utero may be ascer- 
tained by external and internal examination. The external proof is the size and consistence 
of the abdomen, the parietes of which, if there be another child, remain nearly as tense as 
before the expulsion of the first ; but this is not invariably conclusive, because the uterus may 
remain so uncontracted from other causes, as entirely to occupy the cavity of the abdomen. 
After applying the hand to the abdomen, or a finger or two in the vagina, should there remain 
any doubt, it will be prudent to pass the whole hand into the vagina, rather than leave his 
patient under any uncertainty. On the management of twins some diversity of opinion exists, 
as to whether the birth of the second should be purely artificial or left to nature. Several 
cases are on record where the second child has been retained many hours, or days, and even 



. . i Vide Merriman's Synopsis. 



weeks, without mischief.* Hence it has been supposed by some that the birth of the second 
child might be left to an indefinite period, provided no untoward circumstance should super- 
vene to render artificial interference necessary. Others again, in anticipation of danger, pro- 
ceed to deliver the second child immediately after the birth of the first. But the most expe- 
rienced accoucheurs wait a certain time (from one to four hours), provided the first child was 
delivered by the natural efforts, and no untoward circumstance, as convulsions, hemorrhage, 
&c, should take place. But if the child should present in a wrong direction, it has generally 
been considered expedient to extract it by the feet with as little delay as possible. If also the 
first labor have been preternatural, dangerous, or difficult, it is, with some, an additional 
reason for delivering the second child as expeditiously as circumstances will permit. 

In some cases it may be sufficient merely to rupture the membranes, in order to bring down 
the feet, or to render such assistance as the individual case may require. 

* Vide Medical and Physical Journal for April, 1811. 



TABLE XII. 

Represents an injected uterus at the full period of gestation (about half its 
natural size), intended to illustrate the enlarged size of the vessels, their distri- 
bution and anastomosing with each other. 

B. — The tube behind which the ovary lie concealed. 

C. — The neck of the uterus. 

D. — The spermatic artery. 

E. — The spermatic vein. 

F. — The hypogastric vein. 

G. — The hypogastric artery. 



t 



TABLE XII 




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TABLE V. B. 

ILLUSTRATING PLACENTA PRESENTATIONS, ADHESION OF THE 

PLACENTA, &c. &c. 

Fig. 1 — Represents the abdomen and uterus laid open, (the anterior part of 
the uterus being removed, to shew the placenta, partially situated over the 
cervix uteri). The foetus is seen through the amnion. The operator's hand is 
represented as introduced into the vagina, about to rupture the membranes; 
the direction of the fingers in the vagina are represented in outline. 

A.A. The abdominal muscles, integuments, &c. turned back. 

B.B. The cut edge of the uterus. C. The placenta. 

D. The foetus. E. The hand of the operator. F.F.F. The fingers in 
the vagina. 

When the placenta is situated over the cervix uteri, very alarming and dangerous flooding 
commonly occurs, from about the sixth or seventh month to the full period of gestation ; and 
no woman can be said to be free from danger until she be delivered : hence the interposition 
of art is demanded, and must be timely applied, or the woman will be lost : and we are told 
these cases ought never to be trusted to the powers of nature.* 

The manual assistance required in these cases, is to deliver the woman as expeditiously as 
the urgency of the case may demand. The precise time when the patient ought to be deli- 
vered must depend in every individual case upon the quantity of blood lost and the effects pro- 
duced. When the delivery is determined upon, (the usual means for suppressing hemorrhage 
having failed), the operation should always be performed with the utmost deliberation. When 
the lingers reach the placenta, it is of little consequence whether we perforate it, or insinuate 
the fingers on one side till we come to the edge ; though the latter is generally to be pre- 
ferred ; and when the os uteri is only partially covered with the placenta, (as here delineated), 
the hand may be passed by its edge to the membranes without difficulty, which is preferable 
to boring through the substance of the placenta. f So soon as the hand has attained admission 
into the uterus, the operation of turning is to be performed, under the guidance of the direc- 
tion given under the operation of turning, (see Table VI). In bringing down the child, (as 
in all preternatural cases), it should be done gradually ; the pressure of its body, as it ad- 
vances, will stop the flooding ; and should there be pains, the obstetrician must extract at such 
times, resting between ; but if there be no pains, it may be proper to rest at intervals ; for, by 
hurrying the delivery, the woman may be so much fatigued as to be in danger of instant dis- 
solution ; the flooding being stopped by the child's body, the more immediate danger is 

*See Conquest's Outlines, Denman's Aphorisms, &c. 
t Ryan's Manual, &c. Blundell's Lectures, &c. 



checked ; the head of the child being suffered to remain a little time in the vagina, will give 
the uterus opportunity to contract on the placenta, by which means it will be sooner expelled, 
and the flooding stopped. 

The placenta, when situated over the os uteri, is much thicker than in common, but less 
in circumference. When examination takes place, particular caution should be observed, 
that coagulated blood be not mistaken for the placenta. 

Fig. 2 — Represents the same section of the parts, with a delineation of the 
placenta, situated directly over the os uteri. 

In this situation of the placenta, it may be required to perforate the substance of the mass 
with the fingers, and to pass the hand to the feet of the child, and bring them down through 
the aperture. 

Fig. 3 — Represents the hand introduced into the uterus to remove the pla- 
centa, the funis being separated. 

This accident, (the separation of the funis), may arise from great force being used in ex- 
tracting the placenta ; but sometimes it takes place when very gentle force only has been used ; 
the funis being small and of a flimsy texture, or not being firmly united. The separation of 
the funis may be attended with some inconvenience to the young practitioner, should the pla- 
centa not be expelled by the action of the uterus in due time, (or if attended by flooding), 
being deprived of his immediate guide by the loss of the funis. But no great difficulty will 
be found by the operator who has a proper knowledge of the anatomy of the parts ; the hand 
being cautiously introduced into the uterus, the placenta is to be gently withdrawn in the 
direction of the axis of the pelvis. 

Fig. 4 — Illustrates the detention of the placenta, caused by adhesion between 
the uterus and placenta. 

This adhesion arises in consequence of the deposition of coagulable lymph from inflam- 
matory action, which may have existed during gestation, probably caused by some external 
injury.* 

The adhesion is most frequently only partial, but sometimes unites the whole surface of the 
placenta to the uterus. 

The unaided efforts of the uterus, as Dr. Conquest very justly observes, can never detach 
and expel the placenta under these circumstances ; hence the interposition of art becomes ne- 
cessary for its removal from the uterus. The hand of the obstetrician must be carefully intro- 
duced into the uterus, and, feeling for the edge of the placenta, cautiously and deliberately 
insinuating one, two, or more of his fingers between the placenta and uterus, slowly and ten- 
derly separate the former from the latter. The hand should not be withdrawn until the sepa- 
ration is completely effected and uterine action excited. 

* Vide Ramsbotham. 



Fig. 5 — Represents detention of the placenta, caused by irregular or spas- 
modic affections of the muscular fibres of the uterus, constituting the hour-glass 
contraction. 

Spasmodic contraction of the muscular fibres of the uterus may occur either in the circular 
or longitudinal ones ; when in the former, it produces either the hour-glass contraction, di- 
viding the uterus into two cavities, (as represented in the drawing), or closes the cervix uteri, 
from which cause the placenta is detained. The management, in these cases, consists in 
allaying the spasmodic action, by the exhibition of an anodyne : from 40 to 60 minims of 
tincture of opium will generally have the desired effect ; and, usually within half an hour, the 
constricted part becomes relaxed and dilatable, and the hand may be cautiously introduced 
into the uterus through the stricture. 






TABLE VI. B. 

THIS TABLE IS INTENDED TO ILLUSTRATE THE OPERATION OF TURNING. 

Fig. 1 — Represents a front view of the pelvis and uterus, the anterior por- 
tion of the uterus being removed to shew the situation of the foetus, with left 
arm presenting, also the hand of the operator in the act of grasping the feet. 

The position of the patient during the operation of turning is not very material, provided 
it is that which gives the operator the free use of his hand and arm. Some recommend that 
the patient should be placed on her hands and knees ; and others, that she should lie on her 
back; but the usual position, i.e., on the right side, is probably as convenient as any; and 
during the operation it may be found convenient to change one position for another, under 
particular circumstances. The operation may be performed either with the right hand or the 
left ; when the feet of the child lie forward to the forepart of the mother, the right hand will 
be usually found most convenient ; but if the feet lie to the back of the mother, they will be 
most readily come at by the operator using his left hand. Previous to commencing the opera- 
tion, the arm should be laid bare, and, to facilitate its passage, the back of the hand and arm 
should be well smeared with some greasy substance, as pomatum, lard, sweet oil, or a lather 
of soap and water. 

Fig. 2 — Represents the same sections of the parts as the preceding drawing ; 
in this, the hand of the operator is seen grasping both feet of the foetus, and in 
the act of drawing them through the os externum, the presenting arm of the foe- 
tus retracted, the back raised towards the fundus of the uterus, and the buttocks 
towards the right side. 

It has been taught by most authors, to lay hold of both feet, as the turning is more readily 
and safely accomplished ; but it will frequently happen, especially when the waters have been 
some time discharged, and the uterus strongly contracted round the body of the child, that we 
must be content to lay hold of one foot, rather than use any violence in our search for the 
other ; a very intelligent teacher of midwifery, Mr. Radford, of Manchester, recommends in 
every case to turn with one foot only, believing that the extended extremity upwards secures 
the funis from compression during the passage of the body through the outlet. 

Fig t 3 — Illustrates the same section of the part, with the further advance- 
ment of the foetus through the os externum, with the arms of the foetus extended 
on each side of the head, the hand of the operator grasping the nates and thighs. 



< ^ - p^*^ 







- 









So soon as the nates are brought within the hollow of the sacrum, the case becomes pre- 
cisely similar to a foot presentation ; the object of the operator will now be to give such an 
inclination to the body of the child as will direct the face towards the back of the mother, the 
most desirable position for the passage oftJie head: if the toes of the child are turned towards 
the belly of the mother, the head must come in an unfavorable position ; but, if the toes 
point towards either sacro-iliac synchondrosis, the child is already advancing favorably. 

In giving this inclination to the body, it is not necessary that the parts of the child should 
be completely turned, an inclination towards the mother's back being sufficient. The turn 
should be cautiously effected, without force, and during the time of a pain. 

Fig. 4. — In this figure the further progress of the child towards delivery is 
seen ; the head is represented in the cavity of the pelvis, the forehead turned to 
the hollow of the sacrum, and the occiput advancing from under the arch of the 
pubis, the right hand of the operator in the act of bringing down one of the arms. 

In presentations of the lower extremities, and in those rendered so by the operation of 
turning, it is a question if it be best to deliver with the arms extended above the head, or to 
draw them down by manual assistance. We would say, in breech cases, where the labor 
has advanced slowly and without the interference of art, and in crural cases, where the os 
uteri has become perfectly relaxed and fully dilated, it may be attended with some advantages 
to bring down the arms, especially if there be any contractions of the pelvis, or the head of 
the child be large. But in presentations of the feet, or where the operation of turning has 
been performed, when from some untoward cause it has been thought expedient to hasten the 
passage of the body through the pelvis, it is often better not to attempt to bring the arms 
down, lest the os uteri should contract round the head ; or, as some suppose, round the neck 
of the child,* and thus impede the passage of the head, or cause the death of the child. 

To bring the arms down, we pass one or two fingers over the shoulder of the child as far 
as the bend of the elbow (see drawing), which is then to be gently depressed, when the fore- 
arm usually passes through the vagina with little difficulty. 

Should the operator's fingers be unable to reach the head of the elbow, or not readily dis- 
lodge the arm, it would be prudent to give up the attempt, rather than risk an injury to the 
child. 

In first pregnancies, it will require care, as the arm passes, to guard the perinseum from 
laceration. 

" The head being brought into the cavity of the pelvis, and the face turned to the hollow 
of the sacrum," the body of the infant should be raised towards the abdomen of the mother, 
by placing it on the left arm of the operator, as represented in the sketch, fig. 5. The index 
and middle fingers of the right hand are to be placed on the neck of the child, and the index 
of the left in the mouth, to depress the chin ; when gentle traction in the axis of the outlet, 
during uterine action, will usually accomplish delivery. Should there be no uterine action, 

* Dr. Merriman " believes that it very rarely takes place round the neck of the child," and says 
"when it does happen, it is round the upper part of the child's head, girding it like a band in a line just 
nbove the nasal bones in front, and below the projection of the occipital bone behind." 



we should excite it by friction on the abdomen, or by the ergot, or the child may be lost by 
pressure on the navel string.* 

Sometimes considerable difficulty attends the passage of the head. Should the child be 
affected with hydrocephalus, the fluid must be let out by the trocar or perforator, either behind 
the ear or at the back of the neck. 

The following caution should be attended to in performing the operation of turning : — 

The hand should not be introduced during a pain, but in the interval. 

The os uteri ought to be dilated to the size of a half-crown, and dilatable, to justify the 
introduction of the hand. 

Care should be taken to ascertain correctly the position of the feet, before passing the hand. 

The danger in turning arises from the contraction of the uterus round the body of the 
child: hence, when the uterus acts powerfully (the waters being discharged), we must over- 
come this resistance, by exhibiting fifty or eighty minims of the tincture of opium, or three 
grains of the gum ; when anodynes fail, a copious bleeding may be tried. When these 
fail, it has been proposed to exhibit the tartarised antimony, so as to produce nausea, f 

Turning ought never to be performed until the bladder and rectum have been evacuated. 

The operation of turning is required when any part of the infant presents from the base 
of the skull to the breech ; it is also required in floodings, when the placenta is attached 
over the os uteri, and in some other dangerous haemorrhages, &c. ; and also in some funis 
presentations. 

* Ryan's Midwifery. t Ryan's Manual, page 523. 



TABLE VII. B. 

ILLUSTRATING THE OPERATION OF CRANIOTOMY. 

Preliminary Remarks.— The cases demanding this operation are those in which there is so 
much disproportion between the size of the head of the child, and space within the pelvis, as 
not to admit the passage of the former through the latter. This disproportion may arise either 
from the pelvis being contracted, or from the extraordinary bulk of the infant's head, or from 
tumor, &c. in the parturient passages : the former is the most frequent cause. 

The precise diameter of the pelvis through which an infant at the full term of gestation can 
pass, without reducing the bulk of the head, has not been accurately nor satisfactorily deter- 
mined. Dr. Clarke, of Dublin, says that 3| inches from pubes to sacrum is the least diameter 
through which he has known a full-grown foetus to pass entire.* Dr. Osborn says 2| inches. f 
But the term full-grown fetus is indefinite and unsatisfactory as regards the size of the foetus ; 
for one full-grown foetus may readily pass through a diameter of 2f inches, whereas another 
would with difficulty pass a diameter of 3| inches ; such is the disproportion between children 
born at full maturity : we can at all times more readily measure the diameter of the pelvis, 
than ascertain the dimensions of the foetal head. J Dr. Ryan says (Manual of Midwifery), " If 
the sacro-pubic diameter is only 2\ inches, and the transverse or bis-iliac 3 inches, craniotomy 
is justifiable ; but if the short diameter is only 1\ inch, the operation would be useless, and 
dangerous." 

Dr. D. Davis (Vide Elements of Operative Midwifery) has invented an instrument, which 
he denominates the osteotomist, for breaking down the foetal skull and bringing it away piece- 
meal. With this instrument he considers it practicable to deliver in cases of extreme distortion, 
when the diameter is less than two inches ; and also recommends its use in breaking down the 
skull in preference to using much force, in cases less contracted. 

Craniotomy may also be indicated if the foetus be dead, and the parturient passages so con- 
tracted as to preclude the possibility of delivery either by the forceps, lever, or by turning, or 
when the head remains in the pelvis, and the hand, forceps, or blunt hook, is insufficient for its 
extraction. This operation may now and then be demanded in face presentations and preterna- 
tural labors, when the head is too large to pass the superior aperture of the pelvis. 

The time when the operation of craniotomy should be performed, must depend, in every 
case, on the state of the patient. It has been frequently performed too late to save the life of 
the patient. In cases of distorted pelvis affording no possible chance of a natural delivery, 
we should have recourse to the perforator so soon as the orifice of the uterus is sufficiently 
dilated to admit of its convenient and safe employment ; but in cases of doubtful sufficiency 
of space to admit of a living birth, we must delay the operation so long as any chance remains 
of a natural delivery, consistent with the safety of the mother. 

* See Transactions of the Dublin Association, &c. vol. i. p. 374. 

t Essays on Midwifery (1794). p. 194. 

t On the mode of measuring the pelvis, see Tab. III. Obstetric Tables. 
11 



V 



DESCRIPTION OF TABLE VII. B. 

Fig. 1 — Represents the lower part of the abdomen, &c. the female lying in 
the dorsal position, with the left hand of the operator in the vagina, guiding the 
point of the perforator. 

The operation of craniotomy may be performed when the patient is lying in the usual posi- 
tion, " left lateral," or as here represented ; the latter is the most convenient for the operation. 

On commencing the operation, an assistant should make gentle pressure on the abdomen, 
so as to keep the uterus steady and the head of the foetus fixed during the operation. 

The first part of the operation consists in introducing two or more fingers of the left hand 
into the vagina, then to carry them forward and place them, if possible, on the sagittal suture 
or anterior fontanelle, then introduce the perforator, and pass it along the palm and fingers till 
it reaches the head, and, with a semi-rotary motion, penetrate the integuments and gently push 
forward the instrument, till it reaches the stops. (See C. fig. 2.) 

On turning aside the parts of the drawing marked A, the relative positions 
of the foetus, pelvis, $$c. are brought into view, the anterior part of the uterus, &c« 
being removed to demonstrate the situation of the foetal head and bones of the 
pelvis, &c. 

Fig. 2. — B. The head of the foetus. C. The Symphysis pubis. 
D. The Sacrum. E. The upper part of the Vagina. 
F.F.F.F. The cut edge of the Uterus and Vagina. 

The perforator being passed to the stops, or rests, we are now to open the blades to the 
extent of an inch or two, close them, and open them again transversely, so as to make a cru- 
cial incision. (See fig. 3, on turning down fig. 2.) The cerebral mass is now to be broken 
up by moving the blades in various directions. The blades should now be closed, and the 
instrument gently withdrawn from the vagina. The brain now generally escapes, the bulk of 
the head becomes considerably reduced, and the child may be expelled by die uterine con- 
tractions, without farther interference. Should this not take place, unless some untoward 
symptoms demand immediate delivery, we may wait for some hours without any further inter- 
ference, during which time the contents of the head will be forced out by the contraction of 
the uterus, the bulk of the head reduced, and the child may be expelled by the parturient pains ; 
should this desirable circumstance not follow, the crotchet or craniotomy forceps must be 
applied, to complete the delivery. (See fig. 4, on turning down fig. 3.) 

Fig. 4 — Represents the same section of the parts described in fig. 2, with 
the crotchet introduced into the perforation of the cranium, and the left hand of 



\ 



TABLE VII. B. 




iU. del 



the operator in the vagina, to guard the passages against laceration, should the 
instrument slip from its hold, in drawing the infant through them. 

The modern craniotomy forceps have now nearly superseded the crotchet,* as an extracting 
instrument ; with the former we are enabled to use more power, with much less risk of doing 
violence to the parturient passages ; and whichever instrument might be used, we must, in 
every stage of the extraction, draw down the head in the direction of the axis of the pelvis 
with great caution. The extracting force should be very moderate at first, but may be 
gradually augmented according to the exigency of the case. The operator should examine 
from time to time during the extraction if there be any pointed pieces of bone projecting be- 
yond the integuments which might wound the passages ; if so, they should be cautiously 
removed. 

* There are many modifications of the craniotomy forceps recommended by obstetric teachers ; of 
those we have seen, we give the preference to the forceps improved by Mr. Holmes. Fig. a, Table VII, 
is a sketch of that gentleman's forceps; he says, " they are to be introduced closed, till the point of the 
concave blade h reaches the perforation ; it is purposely made longest, that it may slide over the outside, 
while the convex blade i begins to open and enter the perforation ; this blade, i y is furnished with three 
chisel-shaped teeth, /././. ; they enter, while closed, three corresponding holes, k.k.k. in the opposite blade. 
Fig. 3 shews the inner faces of the blade h and i ; smaller pointed teeth are also fixed in the blade h } 
with small corresponding holes in the blade i; these secure the integuments, while the three chisel-shaped 
teeth pass through the bones of the head, and enter the perforations in the blade /t." 



APPENDIX. 



ON LABORS ATTENDED WITH CONVULSIONS. 

The convulsions which occur during pregnancy and parturition very much resemble 
epilepsy ; but to the symptoms these have in common, may be added, the peculiar hissing noise 
which women almost universally make with their lips during the convulsions. 

Sometimes puerperal convulsions come on without any premonitory signs ; but, in most 
cases, they are indicated by a piercing pain in the head, by giddiness, and other vertiginous 
complaints, by blindness, a sense of fulness and tightness about the head, by vacillation of the 
mind, or slight delirium, by violent cramp or pain at the stomach, by fulness or apparent 
strangulation of the neck and fauces. The pulse is usually full, hard, and very slow ; but 
sometimes very rapid, and soon becomes small and feeble. The patient sighs often and 
deeply. When these symptons are not relieved by very active treatment, they are followed 
by a sudden deprivation of sense ; the voluntary muscles first become rigid, and then violently 
agitated ; the eyes roll, the teeth are fixed, and the whole countenance distorted, swollen, and 
livid ; stupor follows, which continues from a few minutes to an hour, or longer ; when the 
woman recovers, with sensations of extreme fatigue, and entire oblivion of the paroxysm. 
Sometimes the fit ends in apoplexy ; or, after consciousness has been re-established for a 
short time, the convulsions return, and continue to recur for hours or days : and if the woman 
be in labor, they re-appear with the pains, and the stupor remains between the fits. 

When convulsions happen to women with child, they are generally, but not constantly, 
accompanied or followed with symptoms of labor ; but though the convulsions may be removed, 
the child is most frequently born dead. 

Convulsions occur more frequently in first than in subsequent pregnancies or labors, and 
may appear at any time after the sixth month of utero-gestation. 

It is of importance to distinguish genuine puerperal convulsions from hysterical paroxysms, 
which they sometimes resemble. They may be discriminated by bearing in mind that, in 
hysteria, the pulse is very rarely affected ; the paroxysms come on without the usual premonitory 
symptoms of convulsions, and attack feeble, irritable women, rather than those who are robust, 
the usual subjects of convulsion. 

Treatment. 

The means to be used for the prevention or cure of convulsions, when threatened or 
existing, must be regulated according to the constitution of the patient and the violence of the 



symptoms. It will always be necessary to take away blood ; and it should be abstracted 
early, rapidly, and abundantly, that the vessels of the brain be unloaded : and it has been 
found particularly serviceable to open the jugular vein or temporal artery. 

In this formidable disease, we are to regulate the depletion, not by the quantity drawn, 
but by the effects produced ; and it will often be necessary to repeat the blood-letting more 
than once in the first few hours ; after which more may be taken by cupping and applying 
leeches to the temples. Emetics, when they can be given, and nauseating doses of emetic 
tartar, will be conducive to the reduction of vascular action. From five to ten grains of 
the hydrargyri submurias, followed by a solution of magnesia? sulphas, may be given. Croton 
oil has also been found useful. Clysters should also be given, to thoroughly evacuate the 
alimentary canal. The scalp must also be shaved, and cold evaporating lotions, or pounded 
ice in. a bladder, should be constantly applied to it. It will also be prudent to empty the 
bladder. 

Some practitioners have recommended the speedy delivery, as the most eligible and only 
effectual method of removing puerperal convulsions ; but others have insisted that the labor 
should be uninterrupted. From the result of careful observation, made in numerous instances, 
it appears, that if the os uteri be rigid and undilated, any attempt to introduce the hand into 
the uterus, to expedite delivery, aggravates the convulsions ; and, even when the os uteri is 
dilated, such an attempt will often bring back the paroxysms. 

Should very urgent symptoms appear to justify delivery, before the head of the child 
has descended so low as to be within reach of the short forceps, either the long forceps or the 
perforator are to be preferred to the introduction of the hand into the uterus ; excepting those 
case in which the parts may be well dilated, or in presentation of the arm, in which it is always 
necessary to change the position of the child by turning. 

When puerperal convulsions continue after delivery, which in some instances they do, it 
will be necessary to persevere in the plan of treatment laid down, with the addition of counter- 
irritation by means of blisters applied to different parts of the body. 



ON ABORTION, &c. 

The predisposing causes of abortion are, general indisposition of the constitution, and an 
irritable and feeble condition of the uterus, not admitting of its distention beyond a certain 
extent, and premature development of the os uteri. Every action in common life has been 
assigned as the exciting cause of abortion ; but it is to the excess of these actions that we are 
to attribute their effects. Plethoric women are more liable to abortion, from the peculiar 
disposition which the vessels of the uterus have, from structure and habit, to discharge their 
contents. Weakly women are liable to abortion, because they are susceptible of violent 
impressions from slight external causes. 

Treatment. 

As every disease to which women are liable may dispose to abortion, the remedial means 
to prevent it must be accommodated to the disease, or to the state of the constitution. In the 
majority of cases, there is local congestion, which demands repeated bleeding in small quan- 



tities, either general or topical, by leeches or by cupping ; and the diet should chiefly consist 
of ripe, subacid, or dried fruit. If there be debility and irritability, recourse must be had to 
a nourishing and invigorating diet, and medicines, sea air and cold bathing, cold water 
injections per vaginam or per anum. In every case, it will be proper to avoid all violent 
exercise, to keep the mind composed, and to rest frequently in a horizontal position. Sexual 
separation should be enjoined. 

If uterine action be established, abortion can be but rarely prevented ; but it should be 
attempted, by general and local bleeding ; by injecting, per anum, three or four grains of 
opium, previously rubbed down with cold water ; by cool air, light covering, and by the 
exhibition of nitras potassse. 

Opium should not be given, unless with the intention of temporarily subduing the 
contractile efforts of the uterus ; which may be arrested for a time ; so that, when they recur, 
it may be with augmented power to expel the ovum. The secale cornutum may be given to 
advantage to assist the uterine efforts. 

There is an endless variety in the manner in which abortion takes place ; some women 
abort with sharp and long-continued pains, others with little or no pain ; some with profuse 
and alarming hemorrhage. The hemorrhage in abortion is not always in proportion to the 
period of pregnancy. 

The hemorrhage usually depends upon the difficulty with which the ovum may 
be expelled, and upon the state of the constitution naturally prone to hemorrhage. If 
the woman's life be endangered by hemorrhage, every medicine or application which 
has the power of slackening the circulation must be used ; cold or astringent injections 
into the vagina, or even a piece of ice may be introduced within the vagina; dashing 
cold water on the abdomen ; and the exhibition of lead internally, in combination with opium 
and acetic acid. Plugging up the vagina with a piece of lint or sponge has been sometimes 
used with advantage, by favoring the formation of coagula. Sometimes the hemorrhage is 
kept up by some portion of the ovum remaining partly within the uterus. Should circum- 
stances seem to demand it, this may be removed by a careful application of the fingers. The 
ovum has been retained in the uterus for many months after the symptoms of abortion had 
appeared, and when it had lost the principle of increasing ; but it is not thought proper to use 
manual or instrumental assistance for bringing the ovum away. Abortion occurs more 
frequently at the sixth, tenth, and twelfth weeks, and at the seventh month. The exciting 
causes of abortion, at those periods, should be carefully avoided. 

ON HEMORRHAGE. 

Hemorrhage, previous to or during the time of parturition, must be considered an occur- 
rence of considerable danger, and as one demanding prompt and active interference. Uterine 
hemorrhage may occur before, during, or subsequent to the birth of the child; and is either 
accidental or unavoidable. Accidental, when occasioned by the separation of a part or the 
whole placenta over the os uteri. Hemorrhage arising from the first cause is not so dangerous 
as those from the second ; nevertheless it sometimes proves fatal. The danger attending 
hemorrhages is to be estimated from a consideration of the general state of the patient, of their 
cause, of the quantity of blood discharged, and of the effects produced, which will vary in 



different constitutions. Hemorrhages are infinitely more dangerous with sudden than with 
slow discharges of blood, even though the quantity lost be equal. 

From whatever cause flooding may arise, the following general directions will be applicable, 
and should be rigidly observed. An horizontal position, cold applications of vinegar or salt 
water to the pubes and loins ; vinegar and cold water may be injected into the rectum, and a 
piece of ice, if it can be obtained, introduced into the vagina; but very slight covering to the 
bed, and freely admitting as much cool air into the room as possible : as little food as possible 
should be given, avoiding all kinds of stimulating drinks and medicines. By these means the 
hemorrhage will frequently cease, or be so much diminished as to place the woman out of 
danger. 

Should such measures not be successful to arrest the progress of accidental hemorrhage, 
two modes of proceeding have been proposed. First, to deliver the woman by turning the 
child and delivering by the feet ; secondly, to merely rupture the membranes, that the liquor 
amnii may escape ; the uterus, by contracting on its contents, may so far diminish the 
hemorrhage, that the woman may go on with safety until the child is expelled. 

Of the propriety of this delivery there is no doubt, except as to the precise time when it 
should take place. On the first appearance of the hemorrhage, unless it be prodigious in 
quantity, or unusually untoward in its effects, it is seldom either requisite or proper to attempt 
to deliver by art ; nor does it often happen that a second or a third return of the discharge 
compels us to do so. 

The first method appears best adapted to those cases in which there is an absence of all 
uterine action, or in which the pains are extremely feeble and inefficient, with a relaxed 
condition of the cervix uteri. The second method is applicable to those cases in which there 
are labor pains, and almost always with success. Unavoidable hemorrhage is caused by the 
implantation of the placenta over the cervix uteri. Though the placenta be attached over the 
cervix uteri, the woman usually passes through the early part of pregnancy without any 
inconvenience ; but flooding may occur, at any time after the fifth month, whenever the 
expansion of the cervix uteri lacerates those vessels which pass between it and the placenta. 

But when the changes previous to labor come on, there must be hemorrhage; and the 
patient is never free from danger till she is delivered ; and as the delivery is seldom completed 
by the natural efforts, we must be careful not to delay the delivery too long. 

Sometimes the placenta is retained from torpor or irregular contractions of its fibres, and a 
profuse discharge of blood, when no action is exerted by the uterus to expel the placenta ; 
and this is found to be by far the most common cause of hemorrhage at the time of delivery 
Whenever there is hemorrhage, the whole or a portion of the placenta must have been pre- 
viously separated ; and the hemorrhage usually continues, or returns, till the placenta is 
expelled, or extracted out of the cavity of the uterus. A loss of contractile power exists in 
various degrees ; sometimes to such an extent, that the hand, introduced into the uterus, may 
be carried up to the scrobiculus cordis, without restoring its contractile powers: the extraction 
of the placenta is therefore to be considered as the only method by which an apprehended or 
present dangerous hemorrhage is to be prevented or avoided. Internal irritation of the uterus, 
by gently moving the fingers, and external pressure and friction, the application of cold, and 
the exhibition of the ergot of rye, are the principal means on which we must rely to re-excite 
the action of the uterus. When flooding occurs, with retention of the placenta from irregular 



or spasmodic action of the uterus, the hemorrhage will be checked by such means as relax the 
spasms, i.e. a full dose of opium ; when the placenta may be removed, as illustrated at Tab. 
v. B. 

The hand should never be withdrawn from the uterus until it begins to contract, except it 
be to empty the organ of coagula. Syncope or fainting is not an unfrequent consequence of 
flooding ; and although it is sometimes beneficial in staying flooding, it must be viewed 
as an evidence of danger, and as indicative of extreme loss of energy in the vascular 
system. Moderate fainting is beneficial, because, during its continuance, the mouths of the 
vessels often become so sealed by contraction and the formation of coagula, that hemorrhage 
ceases. Hence it ought never to be rashly interfered with, by the exhibition of brandy and 
other stimulants. As a general rule, stimulants are inadmissible in any case of uterine 
hemorrhage ; but when great prostration of the vital powers exists, with syncope, and the 
patient has continued faint so long as to give time for the vessels of the uterus to contract, 
then small and repeated doses of such stimuli as brandy or ammonia must be given ; as also 
nourishment in small quantities, very often repeated. Other means are also to be used ; and 
one of the most effectual is sprinkling the face and chest with cold water. 

12 



ADDENDA. 



TABLE I. C. 

CESAREAN OPERATION. 

Fig. 1. — The different modes of making the incision. No. 1. Baudelocque's 
No. 2. Lauvergeat's. 

Fig. 2. — The mode of the ancients. Commencement of the operation. 

1. Section of the abdominal parieties, in the direction of the Rectus Muscle. 

2. Section of the walls of the womb. 

Fig. 3. — Extraction of the child. 

Fig. 4. — Passage of the sound to convey the umbilical cord through the os 
tincce. 1. The upper end of the sound with the ring fastening the cord. 2. 
The lower end of the sound protruding from the vulva. 

Fig. 5. — The Cephalotribe. 



TABLE I. C. 

HYSTEROTOMY, OR THE CESAREAN OPERATION. 

The artificial opening of the uterus, by an external incision, commonly termed the 
Cesarean operation, is one of the last resorts of science when nature fails, or when unforeseen 
impediments prevent delivery by the natural passages. This operation should of course 
never be performed, except when it is evident that delivery is impossible in any less objec- 
tionable form, or in other words when we have simply the choice of either doing this, with a 
chance of success, or leaving the patient to certain death ! In any case, if the sacrifice of the 
child will obviate the necessity for such a dangerous operation, common sense and humanity 
evidently dictate that the sacrifice should be made. So that this operation should never be 
performed at the risk of the mother, merely with a view to saving the child. 

This operation has met with great opposition and with great commendation. There is no 
doubt, however, but that it is frequently the only resource, though it has probably been per- 
formed in many cases when not imperatively needed. The necessity for it is not so great at 
present as it has been, owing to greater perfection in the structure and uses of various instru- 
ments for extracting the child, particularly the Cephalotribe, which will be described here- 
after. 

That this operation is a most serious one, as much so, probably, as almost any other, is 
undoubted. Some writers have asserted that Jive-sixths of those operated upon die ! Others, 
however, assert that the proportion is not so great ; and it is certain that cases have been 
known where the same person has been operated upon several successive times, and yet fully 
recovered. It is probable that the danger is much decreased by modem skill and science, 
and probably will be still more so. If the modern practice of artificial delivery was prac- 
tised in every difficult case, at an early period, hysterotomy would never be needed, because 
the foetus could then be removed while it was so small as to be passed by the vagina. 

When it is fully ascertained that the child cannot pass through the pelvis, and that the 
artificial opening must be made, the inquiry comes, what way is the best of making it. There 
are three modes of operating in this extremity — that of the ancients — that of Baudelocque — 
and that of Lauvergeat, — each with its advantages and disadvantages. Excepting for the 
difference in making the i?icision, the process is much the same in all the modes. We need only 
describe it, therefore, in that most usually practised, the Ancient. 

The Operation. — The most condensed, and yet detailed description of this important 
operation is given by Maygrier, in his « Midwifery Illustrated," which we therefore quote 
in full. 



« The female being placed on the edge of her bed, and slightly inclined towards the side 
opposite the operator, the latter, holding a common bistoury with a spring blade, makes a 
longitudinal incision from seven to eight inches in length, in the direction of the rectus muscle, 
and one inch from its outer edge, so that the lower angle of the wound is three or four fingers' 
breadth above the pubic region. This precaution is necessary in order that the instrument in 
its progress may not wound the membranous part of the abdominal muscles. 

As soon as the integuments are divided, some portions of the intestine may project through 
the external wound ; this must immediately be very carefully replaced, since if injured severe 
symptoms may follow. In order to avoid this accident, it has been recommended to intro- 
duce a probe-pointed bistoury, in one or the other direction, raising the integuments with the 
instrument, the blade of which is then directed from within outward. 

When the integuments are divided and the edges of the wound are slightly separated, the 
body of the uterus appears, which can be recognised by its globular form, and its shining 
and glistening appearance. We must instantly open it by an incision from above downward, 
in the direction of that of the integuments, and four fingers' breadth in extent, large enough, 
of course, to extract the child. This incision should be made so that its lower angle comes 
at or near the centre of the incision in the integuments. (See Table I. C. Figure 2.) The 
operator then introduces one hand within the uterus, seeks for the child's feet, which he 
grasps and delivers with celerity and prudence. (See Table I. C. Figure 3.) Although the child 
is extracted through the soft parts, which oppose its delivery but slightly, it is not strictly neces- 
sary to proceed as methodically and with the same precautions as when the labor is termina- 
ted in the usual manner. Much caution must however be used. We must always remember 
that this severe operation has been performed to save the child, and that, with all our care, 
its life is endangered by weakness. 

After the child is delivered, the thing most important to the success of the operation is the 
delivery of the placenta, which may be accomplished in two modes ; either through the incision, 
or through the natural passages. The first mode demands no directions : in fact, we have 
only to remove the placenta through the external wound, by the aid of the cord, and to 
deliver it without any other precaution than that required by its passage through the wound in 
the uterus. But to obtain this result, the placenta must be completely detached after the 
delivery of the child : for if the least force is required, it is infinitely better to leave it within 
the uterus, and to wait until the uterine contractions bring it down towards the neck, and to 
extract it from the natural passages. This last process is highly advantageous, as it favors 
the flow of the fluids towards the vagina, and thus turns them from the wound in the uterus, 
through which it is always dangerous for them to pass. 

But if the umbilical cord be left in the uterus after the child is delivered, it can pass 
through the neck but rarely, and as in this case we must w T ait until the whole placenta has 
come there, before we can deliver it, it is recommended immediately after the child is expelled, 
and the cord divided, to introduce its cut extremity into the tube of a long gum-elastic sound, 
the opposite extremity of which is directed through the wound in the uterus towards the inner 
opening of the os tineas : in this manner, the cord is brought through the vagina out of the 
external organs of generation, and then the placenta can be extracted. 

Although this mode is ingenious, something was still desirable, since the cord not being 
attached to the tube of the sound, might easily escape and frustrate this part of the operation. 



To prevent this inconvenience, we have thought of fitting a moveable ring to the extremity 
of the sound which receives the end of the cord, by which we may tighten the extremity of 
the sound at pleasure, and thus fix firmly the portion of the cord within it. (See Table I. C. 
Figure 4.) 

We ought not to omit mentioning a very serious circumstance which may occur at the 
moment the uterus is divided. Suppose, in fact, that the placenta is attached to the inner 
face of the uterus, in that part corresponding to the incision of this organ, we must neces- 
sarily make a large wound in it ; this might occasion hemorrhage, which would be more 
dangerous, because most of the fluid would come into the cavity of the uterus, and some also 
might be effused into the abdomen. 

However serious this accident might be, we must deliver the placenta, and even remove 
its divided portions through the w T ound in the uterus, as quickly as possible. This is the 
only mode of arresting the hemorrhage, and of preventing the danger which might attend the 
mother from the more or less prolonged continuance of the portions of the placenta in the 
uterus. 

When the delivery of the placenta is happily terminated, the female must immediately be 
put to bed, in a slightly bent position, and the most perfect rest must be enjoined. 

Some practitioners have proposed to apply sutures to the edges of the wound of the inte- 
guments, to keep them in contact, and to favor the formation of a cicatrix : but we prefer 
simply strips of adhesive plaster. Some compresses placed gently on the wound, and a loose 
body bandage, complete the dressing. In fact, if the operation be successful, the uterus in 
contracting soon effaces the incision made to remove the child : the cicatrization of the exter- 
nal wound not being prevented, the female may be perfectly well in a few days. 

Such is the ancient mode of performing the Cesarean operation : it is generally employed, 
even by the moderns, but its severe inconveniences have induced practitioners to substitute 
others for it. In fact, it is evident that in this mode of performing the operation, the abdo- 
minal muscles are divided in different directions, and the transversalis abdominis muscle 
is not cut across, which might retard the cicatrization of the external wound. Farther, in 
performing the operation in this manner, we cannot always avoid the epigastric artery or 
some of its large branches, and even the uterine artery and the appendages of the uterus. 
The placenta, too, which is often attached to the sides of this organ, may also be interested in 
a greater or less extent, and thus give rise to the most alarming hemorrhages. Finally, the 
place in which the operation is performed, may not always be large enough, on account of 
the deformity of the person operated upon, w'hich is sometimes very great. Such are the 
inconveniences, we might almost say the accidents, which attend the Cesarean operation per- 
formed after the manner of the ancients, which have led practitioners to make the incision 
of the abdomen along the linea alba. This mode of operating is termed Baudelocque's 
mode. , 

Baudelocque's Mode. — The division of the abdominal muscles in the Cesarean operation, 
has always been considered by practitioners as a serious circumstance. Violent inflamma- 
tions, the length of time necessary to the cicatrization, and the risk of protrusions of the 
intestines, are in fact very common. 

The last considerations led Baudelocque to propose to make the incision in the abdomen 
along the linea alba. In this mode of operating, the fleshy part of the abdominal muscles is 



not concerned : we also avoid all the other inconveniences mentioned above ; but it also 
presents remarkable disadvantages, which we shall mention after describing the operation. 
Table I. C. Figure 1. JVb. 1. 

In this process, the parietes of the abdomen are divided along the linea alba, and the 
incision is equal in extent to that made on the side in the former mode. This incision com- 
mences at two or three fingers' breadths above the umbilicus, which must be avoided, passing 
on the side of it, and terminates three fingers' breadths above the pubis. In this manner 
nearly all the linea alba is divided, and exposes the uterus, in which an incision is made pre- 
cisely like that mentioned in the former mode. The other steps of the operation are exactly 
like those mentioned above : we shall not repeat them here. 

This process, as we have described it, is doubtless more simple than the preceding, since 
all the inconveniences mentioned in the operation, as performed by the ancients, are avoided ; 
but it presents some others which we must mention, such as the length of the cicatrix, and 
the extreme difficulty of its healing : this exposes females to hernias, which are more difficult 
to reduce and to prevent, because the parietes of the abdomen present no resistance to their 
formation ; on the other hand, if females who have been operated upon become pregnant 
again, they are exposed to new hernias, which may be extremely large, and also to all the bad 
symptoms which they cause. 

We have now to say one word of Lauvergeat's mode, which, like the preceding, presents 
some advantages and disadvantages : but this differs very much in respect to the place and 
direction of the external incision. 

Lauvergeat's Operation. — This scientific practitioner, struck with the great inconveniences 
attending the longitudinal division of the fibres of the transversalis muscle, and with the 
difficulty resulting from it in the cicatrization of the external wound after the Cesarean opera- 
tion as performed by the ancients, proposed to make a transverse instead of a longitudinal 
incision of the abdominal muscles. In this mode of operating, in fact, the fibres of the 
transversalis muscle are scarcely touched; they are separated, rather than divided: and if the 
operation be successful, the cicatrization of the external wound, favored by the flexed position 
of the patient, is very easy. See Table I. C. Figure 1. No. 2. 

But this mode, on the other hand, presents so great disadvantages, that it has been nearly 
abandoned by practitioners, who generally prefer one of the two preceding processes. It is, 
in fact, remarkable for this, that when the operation performed in this manner is about to 
succeed, it must perhaps be rejected: for then the incision of the uterus being suddenly 
brought below that of the integuments, by the quick contraction of this organ, one part of the 
lochiae must inevitably escape into the belly, and cause there serious accidents. 

It follows, from these remarks, that of the three modes of performing hysterotomy, the 
operation of the ancients is most inconvenient, although perhaps it is more easily practised ; 
and it is also advantageous as allowing an easy issue to the lochiae, which sometimes escape 
through the wound in the uterus: so that Baudelocque's mode seems preferable to the other 
two, although the only one which is attended with such fatal consequences : we allude to the 
difficulty of cicatrization, and the inevitable formation of hernias. As to Lauvergeat's 
mode, its advantages do not compensate for the inconveniences which often attend it, and we 
think it should never be performed. 
13 



M. Baudelocque, jun. has recently proposed a new process, which deserves the attention of 
practitioners."* 

Our dissected plate will facilitate the understanding of all these descriptions very mate- 
rially, and in fact makes them as intelligible as they can be made, by any kind of pictorial 
illustration. 



* The following account of M. Baudelocque, jun.'s mode of performing the Cesarean operation, is from 
Dr. Meigs' translation of Velpcau's Midwifery. 

"The incision is commenced near the spine of the pubis, and extends, parallel to Poupart's ligament, 
beyond the antero-superior spine of the ilium. He selects the left side, on account of the inclination of 
the cervix, when the womb is oblique to the right, and the right side where there is a left lateral obli- 
quity. After having divided the abdominal parietes without touching the epigastric artery, he pushes 
away the peritoneum from the iliac fossa, quite down into the excavation, and detaches it from the upper 
part of the vagina, which he opens ; through this opening, which ought to be sufficiently free, the finger 
is conducted into the os uteri, which is now to be drawn up towards the wound in the abdomen, while 
the fundis is at the same time pressed in an opposite direction, so as to make it turn over more readily. 
When the operator has succeeded in bringing the orifice of the womb opposite to the opening made in 
the abdominal parietes, the delivery is intrusted to the uterine contractions, or provided it should be 
absolutely necessary, the orifice might be dilated with the fingers, and the foetus extracted either with the 
hand or the forceps." 



THE CEPHALOTRIBE. 
(See Table I. C. Figure 5.) 

This instrument has done more than perhaps any other to obviate the necessity for the 
Cesarean operation. The following description of the instrument and its use, is taken from 
Chailly's Practical Treatise on Midwifery, a most excellent work. 

"The cephalotribe, or compressing forceps of the head, invented by M. Baudelocque, 
nephew of the celebrated accoucheur, is a most precious instrument, which cannot be too 
positively defended against its traducers. It advantageously replaces all the sharp crotchets, 
and the entire arsenal of cutting instruments, armed with teeth, &c. ; instruments almost as 
fatal to the mother as to the child, and which, I am happy to say, are completely banished 
from practice. 

This instrument, composed of two branches, is applied, like the forceps, at the superior 
strait, on the two sides of the pelvis. In fact, even when it can be applied regularly to the 
head, it becomes altogether useless, if the size of the head must be reduced. 

The important point in this operation is, carefully to guide the instrument into the uterus, 
and to be well assured that the organs of the mother have not been included within the grasp 
of the cephalotribe. Its weight, although much reduced since its invention, renders it much 
less manageable than the ordinary forceps. 

The head being seized, the branches must be articulated, and then brought together by 
turning the manivelle. The firmest and most thoroughly ossified heads readily yield under 
the pressure of this instrument. As soon as the reduction is effected, the accoucheur should 
proceed to the extraction with all possible care ; for spiculse of bone frequently pass through 
the scalp, and may lacerate the maternal organs. To avoid these accidents, the accoucheur 
must give to the cephalotribe a proper direction ; he should endeavor to place the largest 
diameter of the crushed head in apposition with the largest of the pelvis. For this purpose, 
he directs the concavity of the borders of the instrument either to the right or to the left, as he 
may experience more facility in bringing down the head in one or the other direction ; he 
should also introduce the fingers of the left hand, in order to protect, as much as possible, 
the organs from the spiculse of bone which may have protruded through the scalp. 

Some authors have recommended always to perforate the cranium before applying the 
cephalotribe ; but it seems to me that this precept should not be absolute. In my opinion, 
we should commence by perforating when we have reason to hope that this alone will suffice ; 



but when we know in advance that we must resort to the cephalotribe, notwithstanding the 
perforation, there can be no motive in performing two operations when one will be sufficient. 
In a word, the most solid heads cannot resist the cephalotribe ; the scalp is perforated sponta- 
neously, and the brain escapes of itself; this, at least, is what I have always observed in the 
living female, in the manikin, and in the dead infant. The operation is more rapid, less 
dangerous for the mother, and is not so repulsive to the assistants ; and I believe that the 
opinion that perforation of the cranium should always of necessity precede the use of the 
cephalotribe, has been advanced with no other object than to make it appear that this instru- 
ment is incomplete." 



NOTICES OF THE PRESS. 



" Although we possess a number of excellent elementary works on the practice of mid- 
wifery, we are deficient in graphic illustrations, which convey to the mind of the student a 
knowledge of its principles. The works of Hunter and Smellie are too cumbrous, too 
expensive, and want all those points of information which the industry and skill of medical 
men have, since their time, clearly elucidated. The work of Mr. Spratt will supply this want. 
The plates are well executed and ingeniously contrived to exhibit, in a clear and comprehen- 
sive view, all the most important objects which belong to the obstetric department. By an 
admirable arrangement, similar to that which has been adopted by Tuson in the display of the 
different succession of muscular layers, the natural positions of the parts are judiciously shown. 
Besides the delineations and explanations of the figures, the author has given some very judi- 
cious practical remarks. We most strongly recommend this book to the student and to the 
profession. It is a volume alike interesting to both, for it instructs the former, and recalls to 
the recollection of the latter many most important circumstances, which it is impossible for the 
memory to retain in vivid and fresh colours." — Med. and Surg. Journal. 

"The desire of pointing out to the attention of the student whatever is calculated to 
facilitate his acquisition of knowledge, has induced us to notice several works analogous to 
the present. Those which we have hitherto mentioned have related to difficult points of 
anatomy, such as hernia, &c— subjects which are unquestionably much more easily mastered 
by the beginner, with the aid of plans, which he can, as it were, dissect and replace at will, 
than by any other contrivance with which we are acquainted. Some of the more important 
and obscure parts of midwifery have received this kind of elucidation from Mr. Spratt, whose 
ingenious and well-contrived plans we have examined with great satisfaction. They represent 
the impregnated uterus and its contents under various circumstances, and are excellently con- 
trived to fulfil the design for which they are intended. "—Lond. Med. Gazette. 



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